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HomeMy WebLinkAbout4184DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.75 -1 -48 BOX 32 'L OL rl 20 _ I ;� r IL YES El ❑ SITE LOCATION PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'e'�� NO -o-7 Internal Use Repair Permit issued in last 5 years ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland 414 e I - — 4(� 10J(5t, OWNER'S NAME MAILING ADDRESS r/ . APPLICANTr R ❑; Not in Watershed CI Delegated _CI Joint Review Name & Relationship (i.e., owner, tenant, contractor) DATE / © FACILITY IYPE D C MrLAINT # PROPOSED INSTALLER , _' PHONE # 9 4 ql �y ADDRESS �o r �U h �� REGIS�'RATION /LICENSE # Tc Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of�repair and the location of existing and proposed trenches) NOTE`''Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. _ k <� f +� ems.,.. J" • fv:✓�.. C 't► F+ e s>rr . �f,2 �. s� Pr19� ��G- e�w. e s b, i 4-,ae- At.l I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE TITLE✓ Proposal approved th the following conditions: yocurement of any Town Permit, if applicable. Dmission of as built repair sketch in duplicate showing: . Owner's name b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone numb r 3. System repair to be performed i ccordance with the above proposal and condition . Pro osal Appro d Proposal Denied In pector's Signa Yore & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML } Rev. 8/05 WOW DATE - - - - - - - - - -- ; '-A� q SL 2 ze 9D c -- ------------- --------- ------------ ---------------------------- ----- - 7 ------------ Vt. - - ---- - - - - --------- fj -- ----------- ILVIS m q if 9z 99 c; CL ---------------- ------------ �2 ------- --- - ---------- 6Z ------------ save LLge --- -------------- ------------------------- ---- • -- ------ -------- -------------- OLIc ----------- ------- --------------- --------- 0 69 ge X -------------------------- ------ 7 ----- --------------------- ,g 6E in o m - M --- - -- ---- - -------- ---------------- w - ---------- ----------------------- w Lo Ot OCL 11 ------- ----------- --- ------------------------ ------------- --------------------- 9Z M ZL tv ev- ----------------- — ------------- ------------------------------ I 7� 7- zt - -- !� - ----------------- --- ------------ -- croo — ----------- -- --------- ------------- - --- ------ LVEot azL -------------- -- -- -------- --------- Z9 9t zo Sl 9 - ---- ------------------ CVML LL t9 0 ov ---------- ------------ ---- ------------------------ om woo om, ---------- ---- -------- --------- 0, ---- ------------- ---------------- ---------- 09 - - ------------ -- ------- - --- ---- -- - I ----------------- -`I ------------ ------- ---------- - L9 st 69 at ----------------- --------- ------ ----------------------- tovol: U"&M _SS 's ts M oz -- ---- - ---------- OU LZ ----------- ---- ------------------------- --------- stt C zz :zz ------------------------ Lz o Et ------------- --------------- -------- ----- 9Vc9 --------- ---------- 9z ---------- - -------------- 94 LL LO-01, (S66 oz - -------------- StL, 6Z --------------------------- ----------------------- -- te ------------------- 0A C" z . c LLL CU VD, SO JU 9M ------- ------ ----------- Iq ()O,Ovg ------- --------------- ---------------- 9 - - ------------ .0v z LeuL LE'. _ _____ __ _____ _____o ---------------- ----- SC -- ------------- - - - - - -- - - -- 7---- ------------ LLJ --------------------------- pap 6;nA W CA & _towwof Put aii Septic Repair At Johnny Rotten 92 hewitt Street, Lake Peekskill N,Y, 10537 Home (845) 528 -3540 cell phone (914)494 -4525 -- Section 83.75 Bock 1 Lot 48 + Dear Sir or Madam: #1 Install one plastic septic tank 1,000 Gallor,s #2 Install 2 junction box / distribution box #3 install of Leach field ? 2 rolls of 18 ft. /Infilrator [34 "X 75" X 16" 6 or 8 ea and 1 ' /z" stone :...._:i INSTALL BY PHILIP W CASSESE Accomplished Building Contracting ltd 49 sunset hill Putnam Valley N,Y, 10579 Lic — PC 1183A cell 914 -557 -0879 Cell 914-906-1842 home /offer (845)284 -2424 _ � _ , .: ��-.. : � � : —�,e „- � -.. 6rss:. � ... -.. < <r�)= Cam•.: /��F� -:,. T Ye 3. 8 a Sheet - of *PUTNAlVI COUNTY DEPARTMENT OF HEALTH SAO H�.AsTLH FIELD ACTIVITY.REPORT 4' MAW:' ���� � s' g TPL• �� a �� i AnnPF Streets Towne =State . ti Zin illitl' 71L1C -: FINDINGS. r`. �7 • X61.. �' E> 4 1 , Y' i - � S X� •fi E� j r`. �7 • X61.. �' E> 4 1 Tk,)e NO! 7H 4x' . 2+ .�. ro1 � _ � .! :A'.'� -(v. ��.A 'arl�. `'4 A Qb�tV °ter. ! r C t- _�•�ez• 6..aY >y. .S 72� Ftc1' T.O7�ry o rv�Jc. /io T~LIN� pF iy0-- 2�r -20 "kv GE Tic-, AL Z)Q1 ✓t. A� �� zao� Lp�T or 7 , 0 7� h � r-ax O :4o.p/ ."Zo.00 ZU.V O/ E /�.ge' w ol Al