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631- 589 -8100
83.75 -1 -15
BOX 32
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04172
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PUTNAM COUNTY HEALTH DEPARTMENT 4
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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YES Nd Internal Use Only PERMIT it 1"�' i
❑ Repair Permit issued in last 5 years Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland i Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
— APPLICANT
Iq 0Q101,E —TOWN �.fnk?-M LIB'/ /ATM#
CO r9-r`u M OA +=..+ -i -- PHONE #
r
9-15-1 -1
Name &'Relationship (i.e (owner tenant, contractor)
DATE a ,I FACILITY
� TYPE= PCHD
� COMPLAINT MPLAIINT #
PROPOSED INSTALLER bim �a�c f PHONE # g/ _ 7 3!�; — e-0 9_�
ADDRESS J G1 U REGISTRATION /LICENSE # ll
MIM � t � �
Proposal (Inclu s a separates etch to ting the h , property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extol of the r pairs ) , 'J Ae�olade Uld A /;7 /i /1�
I, as owner,agree to
— SIGNATURE
_ . (owned
" ''' I,`1tie septic ilietalI8 ;agree
on this rm
TITLE i l�J%1 �P%_ DATE a� S G o
i the conditionwof this repair"
SIGNATURE -- -- .-J�;C .X �"� TITLE DATE
(installer)
Proposal_Anoa&W with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
/ INTERNAL USE ONLY
Proposal Approved Er Proposal Denied ❑
Inspector's Signature & Title D e Expiration Date
Re it ro sal is in corn liance with a licable codes Yes O No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Sherlita Amler, MD, MS, FAAP
Commissioner of Health
Robert'Morris, PE
'Director of Environmerital'Health r
Robert J. Bondi
County Executive
Department of Health
1 Geneva Road, Brewster, NY 10509
CERTIFIED RETURN RECEIPT REQUESTED
OFFICIAL NOTICE OF NON - COMPLIANCE
July 8, 2010
Dom Santucci
Santucci Construction Corp.
15 Travis Lane
Montrose, NY 10548
Re: 19 Oriole
(T) Putnam Valley, TM # 83.75 -1 -15
Dear Mr. Santucci:
Per our meeting, you are hereby notified that the following item was in violation of Article III,
Section 3.2.A. of the Putnam County Sanitary Code:
"...No person shall undertake to construct, or allow to be constructed, any SSTS modification or repair to
a_ SSTS without first having obtained the written approval for such system from the
.. _ _.... _ qtr- ector; Commisstoner.- - •....�� .. _ .. __ . _ -...._ .. _. - _ __... _. s• .... -; � .. . .
It is sincerely hoped that in the future, you will secure a repair permit prior to any excavation,
change or modification to a septic system regardless of the situation. Should you have any
question regarding this matter, or questions regarding the Department's repair program please
call me at 845- 808 -1390 ext. 43261.
GDR:kly
Respectfully,
:ao 1J ,
Gene D. Reed
Sr. Environmental Engineering Aide
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845.),225,-5418
Nursing Services (845) 278 -6558 Fax (845)178 -6026
Nursing / Home Care Agency (845) 278 -6085 WIC (845) 278 -6678
Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580
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