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4 AUG -29 -2006 10:47 FROM:PUTNAM COUNTY DEPART 845 -278 -7921 TO:96351173 P:1/1
i
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
._PROPOSAL t2o'R`SEiWAGIE'Di$POSAL 8,YSiEM REPAIR
OWNER'S NAME
MAILING ADDRESS
31 . Ryo ri Ro Pb t Laic e aol- vicLTM #
. k(zU(-1 <, R MON�b PHONE#
sAm
APPLICANT MCI, `ROOT Cat P,. uM (31 N (,-
Namo & Ralatlonship (W., owner, tenant, contractor)
DATE 3J( L-:EL&— FACILITY TYPE -PCHDCOMPtAiNT#
PROPOSED INSTALLER t4Aa 0,00-702 PHONE#
ADDRESS 3 S u I: S� rzo A� i P� ����� �,JL14GISTRATION /i ICENSE #..
ro osal (include a separate sketch locating the house; property lines, all- adjacent wells within 200
feat of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect. ,
w—
I, a caner, or re ci_ ent of own agre to the conditions stated on this form
SIGNATURE G' �� TITLE /�1$fAl DATE v`��`06
P=,oaa,Lapgro a wikh the ivliowina conditlons:
Procuromont of any Town Permit, If applicable.
Submission of as built repair sketch in duplicate showing;
a. Owner's name
b. Site Street Name, Town and Tex Map number
c. Location of installed components tied to two fixed points
d. System description (e.g„ 1260 gal. Concroto septic tank, otc.)
e. Installers' name and phone number
3. System repair to be performed igAbcordance with the
above proposal and conditio
P sal Approved Proposal Denied _
-,
! pector's Signature &Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
S
s�hbster
gov.COM
Department of Health
Septic System Contractor
License No.
�(� C . K6 5 :RA
(name)
COUNTY OF PUTNAM
.- : Reg. # . PC2956 —A
Westchester County Board of Plumbing Examiners
Westchester County Clerk's Office
Master Plumbing License 2006
.Clinton C Kershaw`.
D.O.B: 11/20/1960:'.'...
Height: 5'10 '. We ght :180.
Hair: Brown'.` Eyes: I3fown
Company
Mr RooterlPlumbihj'Y ";;;� .y
PO Box 1740..1,, ;,;.::•`
Pleasant Valley; NY 12569
License No.: 934*
Expires on: 12/3,112006 Mark R. Courtiers:
COUNTY'of ROCKLAND
8QARD 0F.PLUM�ING; HWNG AND.000LING EXAMINERS
This is to certify
CLINTON WSHAW
Is licensed as a
MECHANICAL CON fRACtOR
(X)Pluthbing(.)Heating.j. )cooling �,, r +, 4. I I , e
Llt ense # ;.'P 1 ?O,6 . I' . yr •
State of New 1'
Y6fk` ea�`20.05
EXairiiner
.:... ...:.
I
x. LICENSEa# _ �ster
vCom
Westchester County
HEALTH DEPARTMENT
LICENSED SEPTIC SYSTEM
CONTRACTOR
EXPIRES:
Wesiester
tdOV.COM
Department of Healdi
Septic System Contractor
License No.
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No Ordinary Plumber®
September 21, 2006
Putnam County Health Depatment
Attn: Joe Paravati
1 Geneva Road
Brewster, NY 10509
Re: TM#83.81-1-62, R-216-06 DOH Permit
Kruck, Raymond
31 Avon Road
Lake Peekskill, NY 10537
Gentlemen:
D�
As per our recent telephone conversation, enclosed please find the enhanced as built
sketch with -mole &fdil4§'_iequeste
..-"
If we can provide any farther- infori-nation, please contact our office.
Sincerely,
Irene C. Gagliard0
Icg
Eric: As built sketch
75 West Road e P.O. Box 1740e Pleasant Valley, NY 12569
Tel: 845-635-2102 ® Fax: 845-635-1173
www.mrrooter.com
Independently Owned and Operated Franchise
P
L U
DR 0 0
M
a
No Ordinary Plumber®
September 21, 2006
Putnam County Health Depatment
Attn: Joe Paravati
1 Geneva Road
Brewster, NY 10509
Re: TM#83.81-1-62, R-216-06 DOH Permit
Kruck, Raymond
31 Avon Road
Lake Peekskill, NY 10537
Gentlemen:
D�
As per our recent telephone conversation, enclosed please find the enhanced as built
sketch with -mole &fdil4§'_iequeste
..-"
If we can provide any farther- infori-nation, please contact our office.
Sincerely,
Irene C. Gagliard0
Icg
Eric: As built sketch
75 West Road e P.O. Box 1740e Pleasant Valley, NY 12569
Tel: 845-635-2102 ® Fax: 845-635-1173
www.mrrooter.com
Independently Owned and Operated Franchise
Kruck, Raymond Map 9 -1 -06 — 31 Avon Road, Lake Peekskill, NY 10537
F
0
a
Replaced 5' Section
4 --- 10'
Lawn
Steel Septic
Tank
850 Gallons
t
+ 10' -15'
i
. —D Box
` 1
— Fields i'1
:f
Street
Patio
16'
Minimum 10'
3
<-- Well Pump
Back
u O
Front
Sidewalk
v
S
N
a