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HomeMy WebLinkAbout4239DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.81 -2 -34 BOX 32 ki �ti tip, ,, TL i � �, . '��,I �, r :u. 9 -1 '- �'� 04239 PUTNAM COUNTY HEALTH DEPARTMENT j DIVISION OF ENVIRONMENTAL HEALTH SERVICES P_R POSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES N OV internal Use Only PERMIT # ❑ V epair Permit issued in last 5 years ❑ of in Watershed ❑ epair within Boyd's Corners, W. Branch or Croton Falls Res. [+7' Delegated epair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION 0 gJo ck_ TOWN Lt (e_ fe hk}ll TM # S NAME 1 hf .�C s PHONE # OWNER MAILING ADDRESS 6<),QAJ R4 ,GXk Pf eKA AY /0.4 -3`7 APPLICANT �)A u to & t l'_iCQu C19A4_1�214-cl-&L Name & Relationship (i.e., owner, tenant, contractor) f DATE `7 -0 FACILITY TYPE 9,--11 t- PCHD COMPLAINT # PROPOSED INSTALLER A" 6U„ (pli 04Ai,"Ly PHONE # eV&— _S_J16 aid •%/ $'i�J ( 6 l 0. 3J y ADDRESS 3 tz," Lnl fidc Qelc 1 �L_ REGISTRATION /LICENSE # .30 37-h ( to -� 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. , as owner,agree to the conditions stated on this form r SIGNATURE - TITLE owr,� r- DATE Oe (owner) t, the. sept"� ' s lei-, agree to comply with the conditions of this. permit for the septic system repair SIGNAT46RE ,_S�> CJ( TITLE PA" .c.tt, -r- DATE 711 $/J cS� (installer) Proposal approved 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, perf ormed 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 `Q Proposal Denied ❑ '� 7 2 S © e f �® Inspector's Signature & Title Da)6 Expifation C5ate Repair proposal is in compliance with applicable codes Yes 21 No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 h y Y PUTNAM COUNTY HEALTH DEPARTMENT j DIVISION OF ENVIRONMENTAL HEALTH SERVICES P_R POSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES N OV internal Use Only PERMIT # ❑ V epair Permit issued in last 5 years ❑ of in Watershed ❑ epair within Boyd's Corners, W. Branch or Croton Falls Res. [+7' Delegated epair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION 0 gJo ck_ TOWN Lt (e_ fe hk}ll TM # S NAME 1 hf .�C s PHONE # OWNER MAILING ADDRESS 6<),QAJ R4 ,GXk Pf eKA AY /0.4 -3`7 APPLICANT �)A u to & t l'_iCQu C19A4_1�214-cl-&L Name & Relationship (i.e., owner, tenant, contractor) f DATE `7 -0 FACILITY TYPE 9,--11 t- PCHD COMPLAINT # PROPOSED INSTALLER A" 6U„ (pli 04Ai,"Ly PHONE # eV&— _S_J16 aid •%/ $'i�J ( 6 l 0. 3J y ADDRESS 3 tz," Lnl fidc Qelc 1 �L_ REGISTRATION /LICENSE # .30 37-h ( to -� 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. , as owner,agree to the conditions stated on this form r SIGNATURE - TITLE owr,� r- DATE Oe (owner) t, the. sept"� ' s lei-, agree to comply with the conditions of this. permit for the septic system repair SIGNAT46RE ,_S�> CJ( TITLE PA" .c.tt, -r- DATE 711 $/J cS� (installer) Proposal approved 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, perf ormed 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 `Q Proposal Denied ❑ '� 7 2 S © e f �® Inspector's Signature & Title Da)6 Expifation C5ate Repair proposal is in compliance with applicable codes Yes 21 No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 h rn C) 4 a-L, I R6 ,vn O'A -,A ul Nan I� O O 0 . L • +6 � 9 •'„o AID 30 �gN ;b Sheet of_� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENY'AL,HEATLH SERVICES. FIELD ACTIVITY REPORT NAME: Tel: AT)T)RFq,> 30 /-�Vo,J Yt �y7'/V.�iy✓ - V,�14, r-. Street Town State Zip PERSON IN CHARGE , OR TNTF.RVTFWFT): Plum �JWkn 1latP: i� & 1`%y g Name and Title TYPE OF FACILITY: FINDINGS: Signature and Title RFPQRT RFC F.TVFT) BY., I acknowledge receipt of this report: SIGNATURE; 02/96 Title: ? OU F tl„"'""...• N30° ` aa 3M SIONVtia Y• ^'uAfFMEA, AV 9 ANDRE= `Y � 1�. < SAINT n i.:.� So JOHN' O > �. DR UPLAND °IS.4 I ' Is a .. OX • E r3 /, S RANG co i q RO YLER SpR U UT N ` 'a M31r�' O i N,Dy`0 O � PpGHAMBEAU R � r ` "'^'" R R Fy S BROOK �,q� W � • VILLAGE Tc <� RD) F� LA � DST OR 4 m M �OP4k p o oUNT'9/ a0 °a C7f N \ ' ELM 9° D AIN Ii M PLE R M LE 3 FO Nd °N1 h4J�\ 3 Otl 3NV7 ECAN P N R fgGR '90 '�'HgOjN H /LLA /q \ sA S F BE N <Z EL iy T a RD `\ x PL T 9SF qNQ T RD T9 1S3tlCi� gR m ` HESTNUT9° V p°qD RD <Fhy RO OOK Z _ pF PM rn \ E P M P IS K NORT HO a E H ARGYLE 3 D � �. HOLOW 9SEY �� L C �� 3�oroo i �auRa �� .... gyp, - .'......, "-•�.. �-'A`i..- 1 c�GHOOL O ® M� C ROADWA ® O �Pcc�qq' F TWIN`-- :.,,. -.... 9Gq�4i 5 0H '. NO o5' 9Q � � o K AwgN o 9 RD ° q `, HILL R / sY ..c I�ISYind - - - KNOLLSy 1 local Guy F Sery 3 Fir take Pee Tel: (&! is 'lumbing / Drain ices Inc. ch Lane kill, N.Y. 1,05312 5)526-2471 C -7, 7 3. 2, .00 fN jjt� C 30� A•C 6110`( 6 -C, IV 1q, 6 D -1 tA '7S-0 64,1 low 5Yf " q Qoic-,- 4 'U yCr.,, ubvtjj� k. OL)47— .9 45.51 to 33 /60 :4 /m: 42 34 12211 69.33 STREET F, 58 2 7.4- 97.00 SO. 79 / 81.61 0000 55 SPECIAL DISTRICT INFORMATION I OZ so 20,00 -SC,H- PUTUM v,1-LEY ISTRIcr 37.2 STATE LINE FIRE f- f''i I , ;. PALLET FIRE PROTECTION D13TRICT Cmwy UW DfSFIJM WAS TWN LIFE COAT imms Wei VILLAGE LINE 8LOC` LIMIT PROPERTY LINE -ORIGINAL LOT LINE 1-162 m ROAD ItO.W. STW-WWATMlad SPECIAL OISMIlOr- SCHOOL DISTICM PART OF PARCEL RP r ■ � � ■7=» - -� ■ � � ■7=» f !! AO Ok 1, r - •�.-%c.�:.., o,�, -. _,�_vo s: - .r•.�- -, _c:.c,., _. �7•- _a., r..�. tom._. .._ >. e F f� : ag "e'' .�....:_ •WAS � � � `�� / .-' �!Y }' 1,412 A-3