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PUTNAM COUNTY HEALTH DEPARTMENT
G DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL - FOR - SEWAGE- TREA-TNEPdT SY -STEM- REPAIR..*-.--,.,-.,-.*.,
YES NO Internal Use Only PERMIT 1 \
❑ ,,, ❑���/// - Repair Permit issued in last 5 years of in Watershed
❑ Repair within Boyd's Cpprn�rs, % Branch q Croton Falls Res. Delegated
�%� Le 1l— YzLIC�k.f/
❑ Repair withinC29 of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION S ( —K kC, Dti),,JOWN L A k6 ArM %:, -AJ/rM # ;961
OWNER'S NAME /Yl ;f -t-JA tI Iack E C 114,4 J,0.P1JEA PHONE # 9/-,7-7
MAILING ADDRESS 101 L.kikt 1:j.)4i6-
APPLICANT C00 f 14.11J, -y1u
Name & Relationship (i.e., owner, tenant, contractor)
DATE 101 10�05, _ FACILITY TYPE Si i0. ' ,1.,,,,1 JJ -PCHD COMPLAINT #
PROPOSED INSTALLER rw PHONE # Al 4-735 •-7, M;-
�a�s�sL*t� fL= cwrj�,,�o�7'Y�ls>a.�>y REGISTRATION /LICENSE # '",
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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
Z'*V rlsri di✓ Al ai,;S,49 ti - Sri 4��1 Sr r.rrl rsa� ✓t�
'••• �it/1 ry d CSC [.,,4 ✓✓1 ii G s'✓ .�
I, as owner, ee to conditions stated on this form
✓.e�.�
SIGNATUR TITLE
(owner) /U �_ _
---1; the septic' installer' agree to comply with the-conditions-of this
r
DATE d
system repair ' .
SIGNATURE TITLE DATE
(installer)
Proposal approveCth the Nfollowinci 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 Proposal Denied ❑
: 2
I Title Date( Expiration Date
Re air proposal is in compliance with applicable codes Yes 0 No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
,t l:T- 21;279- 34: 20M FRCM4N1r1P -QNVWA'. HE;L'TH E451787W T-' €&. P.M /0.I
PUTNA.h-1 COUNTY !�•�E,L:TIwi UcF'Ai�TM�NT r
�.�
DIVISION OF NVIF�UKMENTAL H Al TH SEflVICES
Y T S M R CPAJ R/ t -
_ NO __.�_ Imernat t.tae Only PF_Rury
} T
MW S years - rot in i,rl I ?',hed
L-:j' Repair w4mi. Says C,;m jG V& Branco gr ramn Fa s t
.: r l.sl: 3i4
_Qdpdir wIdun e Q.� lot a at9r uu or (its trLfhfd wYllen� t�� .�OM1t i�9vtQW
SITE LOCATJON %C._I )�AIN . A y_.Z-j
OWNFFVS NAME %11,;,„1 (fit �; i i h r '':_fir�.��'tDyn;�Lr"t �P~CJ�tE fir .? k; .,2
MAILING ADDRj..5 �!_" i.__C -a r; t, t?•y,::t- _ � _.....__.. .__ — - --
APPI_iCANT .0rV- ".Y - ra.1,r - - - - - -. �._r
?dame Relal- mnstiip t' e., cAot( !e-nan: �o ^nsMar',
DATA ) th 4� r� - r:ACILITY. 7 r`PL' `.3r 'r.1i ..� baai l'CFil� C:11,:1r'L� Ifrl1 (t
c =—
Ff�(�PC.75EU tiv T a.�i.ER _trltr+ ppmt. fro`
ADD:'-1RS i�!,� • .I�.tJ (.nitit i t.''.r��mC;,:'...�.i r %E ;STRA-I'10M ILK'ENSIr
P� es2i 'inclt3de to separate sketch Iuc2rt6r,g,ihe rncti.ps¢, property limes, .all adj�:cbni wells nithin t)Ci
feet of ropair and the Ideation of exi:rting ina priposed �ystrrm)
N?'i'rr: he De!_: n ,Hilt t 1cly. r� -4U1re s,;arn ta; of proposal fr:7m i ren'i:d irG ?25fiiQ tc7l d0�:8ndY,C� 4� ti`b
nature anti oxtent of the lepor. )
.,�_ _ .._.�..'{. •.N .�+�.s�i [.1...�.�,..,� 5.. _._ �•'�_.t.C'� "_`.._r_ .:.�.,�`� .... �..l..AfaL...�.,e�.CC.�ri:C.,. •�t't�.,�.'`
- - - - ».....___._.... .._.. ".:...�1 -"..�- ,tic r.. r'✓.', EL°: iLt:.::. .,�•r..Y.._._- ...........r..... _. :._..... _ __._.. - -- - -° .
I, as Gvr. ",Pf.B ce Try ttl° io-nrlitons 5tal °1d On 3i i> tUrn'.
SIGNA"UF �% .�i� j�?yTI` [ E.s i� �Jt. �` `►- Ii>- l��!�/
1111,5 �.a.. —✓It� !l 2 '!,�.._ --
(owner) jU q.1" v
)n� taller, three to oexiplywi,�. t ): C'w lejotis G" "his '%iti!I t; ;r n yf lJl.r,.• $!JSt0-M repair
J
+ t ` " ' `7, .jr �'} .. r ,ti TiT! � :1ATE �4 l✓ � •
(installer)
f�rt_ip.f5t3I :c+ o1i.�;'•3 r.!: °i ft q jQ -tI' �- �r_,dllLi'i� . - .. - - -' - -•
... - - - -• . t . ProeuretnEnt of .>xry 'i -awn Pctrlr;A ' appiica:�lr�.
u. Sl cimis4ion Qf as built repair sket:h b? Vw witiC. Q thin• repoir, in dulaiOnt^ :;h•: i';, :;.
a: own (' name, Sita Strrie+t NstmG, burn arid Tax Map number _
b. t.rC,,jtibr bf ir,£;31)d! vomponeim Cad to c+ro Nod ;xknts
c. Sys am deicri'riticn te.g., ,25o gai. - Oon<;reti� sfiptiC tank,
d, ir.9tnticirs riiams and phonfo number.. ..
3. • .system repk:)r to be performed in act- ordance v� the above pthpowi and coiWi;ions
4. The prolmsed 3.STS: repair :s COr ;!JJered a l)f' ! 64 d9.3igf1 and thf -e is t10 giv:irant ee t0 tha "Lralion at wh4j. tn%
cgr.-pletod SSTS repair will hrnC)i,�n,
3. G *0 to b w34 ;s kied rr rS t
_ W'TC RNAL USE ONLY
Pr;tposrt Approved � Pt:pr:;u-i D.:vtiet'
in pec,,vs Signature & !!il Dal
a
Rt:, ;ilr a[ouosa m )� n ca iia.10E vv;lr! 3 lui3Die Cxe,.; DIES t.l NQ
f:OF'1K.S: ' PCHD; Owner; lnt�lalier .
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PIZZELLA BROTHERS, INC.
APPROVED BY:
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DRAWN BY-.
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MEMORY TRANSMISSION REPORT
..�•�»',_... .... j.pF'..- 1e•7-.I•�V:�xi �M" Tr". Y- yFS'. x•{•,..06...sla'�..nR......y.. .Rr' .a x�►.� /' .N'.:40 �0�?' I�. rOI�+ ��' v .•'M�.•�..a•.- �r�....�.....�_te P..:'Y.
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 894
DATE OCT -22 04:28PM
TO 819147883738
DOCUMENT PAGES 001
START TIME OCT -22 04:28PM
END TIME OCT -22 04:29PM
SENT PAGES 001
STATUS OK
FILE NUMBER 894 * ** SUCCESSFUL TX NOT ICE * **
PUTNAM COUNTY HEALTH pEPARTMENT
O pIVISION OF ENVIRONMENTAL HEALTH SERVICES
d PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAI RAJ �] /D1I /may/
vex. u� _ r..e...•.or • .-- A.•..._ 6=__— l - < -,=;? /
(-j U RePalr R—It issued in last 5 yams u Pi fn waxeraneQ
Cl RODetlr .Mtnin Boyd's C�m��. VjS_BranoK9l�Cro[on Fa11s R9a_ OB16gatoo
Q Repair widli Ot s watB•�,+ o - t4G- •napp®d wa[land I� Joint Rewiaw
SITE LOCATION �O LtiJ- FC E.._DecTOWN I ri fc IT,. ?Ogg �.= •%�.7jrM #.
OWNER'S NAME lri:i_14Ar_A �'- Peii.Ac-l•t_ 6 GH4_: j'- rj5l,aj4Grt-___ PHONE 0 `" - �,�•
MAILING ADDRESS �_a-1 L.uYL -0 w::, rr
APPLICANT COry t-/l.Rt�i'dw
Name 8e, Ralatlor[shlp o.a -, owner, tenant, Dontmator)
DATE Il9 I� 1 e.9 �_ t>�r -t� FACILITY TYPE S::+' IL- F, PCHD COMPLAINT a
. PROPOSEa IN$T?.)- LEFT.--- .__.,.: -_._: �i42�L•6�jrr R�ll.ns Si✓ _ _ .._.._ ..__�.- _ - PHONEq�ii i•�7 �� -•��o�
••... _. '••_ -• -+ A' ®OREJ't -�'f�[•r�.t:caST�i t1f�®itrfu�"'+�iacK.r!•:F->- ITT• f' tr5w: t�+•+. �.• �REC3IA 'T.�?A710fd./LI(�rs'PJBEvM•A - vI�►S�[. -•-�•e - ..._� - -.... .......r
Pf000Ba1 (Include a separate sketch locating the house, property Ilnesr all adjaoent wells+ withln Zoo
feet of repalr and tkoo locatie m ad existing and proposed system)
NOTE: The Dapartmant may require submittal of proposal from licensed professional depending on the
nature, and extant of the repair_
.o- {,- x.`s- ,c.�_^7
1, as owner. ee to tYley apnditions stated �on this form
SICiNATIJ Ra . A tit 'A -`.� Y Ylil :r �..[iiJ 4 TITLE
(owner) 62.T'
I, the septic Installer, /agree to comply with the conditions of this arm t for t septic system repair
SIGNATURE ",✓ �`. ��� TITLE DATEiO 9,,Loy
(inataller)
Eronosai Ho OroyaoLwih the failowlna conditions:
1. Proouremnl t of any Town Permit, K appllmbla_
2. Submission of as built repair sketch by iha saptic systarn installer within 30 days of the repair, in duplicato showing:
a_ Owner's name, Site Stroat Name,. Town and Tax Map number _
b. Location of Inatntlad components
nts tied to vo fixed points
c. System doaortptlon (o_g_, 1250 gal. Concreta septlo tank, etc.)
d. Instaliars' names and phone number
3. System repoI to be parrormed In accordance with the nbova proposal and conditions
4. -rho proposed SST$ repair is oonsidorod a best fit design and thorn is no guarantee to the duration at which the
complated SSTS repair will function.
5. No cornplmted work is to be backf)llad until authoriaatlon to do so hiss been obtained from the Department_
Proposal Approved
ra
Proposal Danlad
Daft
on
COPIES: PCHD: Owner: Installer
PC -RP 99ML Rev. 2/07
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