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Home My WebLink About4252DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.82 -1 -2 BOX 32 04252 .� . T. I, . !. �. W IL 04252 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL L-013-SEWAGE-TREATMENT SYSTEWREPAIR YE/ LW Internal Use Only PERMIT # IM rf ❑ pair Permit issued in last 5 years ❑ "in Watershed ❑ rRepair within Boyd's Comers, W. Branch or Croton Falls Res. E"EDNelegated ❑ Repair within 200 ft. of a watercourse or DEC-mapped wetland ❑ Joint Review SITE LOCATION TOWN Pjlti� TM# OWNER'S NAME C. 9-/2 PHONE# Yyf' MAILING ADD SS All !�r a 3 't -24L APPLICANT VW Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE 1'>CJe, le- PCHD COMPLAINT # PROPOSED INSTALLER 40CA G Uq . P/,il -PHONE# ADDRESS LJ Cam_ e_±e JaP(i REGISTRATION /LICENSE # Ce-414 09 9 YY- 6 0 01_35� 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. :2r A -1.4 —r-P �/ ' °9`J." -117.,l_ 1-1 J1 1, as owner,agr toy Z11editio9s,' on this form S SIGNATURE TITLS� 4� DATE a (owner) ifirCiRnsTaffe ith f this p6rh-iit-feFthi-septic-gygtg?n`rdVai-C-'— — F_ J SIGNATURE ` V_y TITLE DATE e 41/0 5� -.%1h th'deonditions-o t (installer) Proposal al2groved with the following conditions: J 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.) cl. 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 B Proposal Denied ❑ ZJ_ -S r -/. Z P -1 Tns;;Fo s Signature & 14tie Ddte Expiration Date ,Repair proposal is in compliance with applicable codes Yes ❑ No A( COPIES: PCHD; Owner; Installer PC-RP 99ML Rev. 2/07 &OW 7 4 Dg-1 say aew-y e2 Y-0 / If I V 7: G-- w 22 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH :SERVICES ` — :x1.,:..•�:— .stir ',<.:'� :>-.- , = - -"-' PROPOSKL' FOR :SEWAGE TREATMENT - SYSTEM REPAIR Internal Use only PERMIT # i ❑ .Repair Permit issued in last 5 years ❑ Not in Watershed . ► ❑ { ., Repair within Boyd's Corners; W. Branch or Croton Falls Res. L],,-'Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint R @Vidal r. SITE LOCATION TOWN ?�.V fit' TM # OWNER'S NAME `w i c 1•, 1vt V -, � . • .',.. PHONE # . ' MAILING ADDRESS a ! 3 e..: °.. °,rs .;r APPLICANT f � :laf,? ,�" rat,. ,: s w707. Name & Relationship (i e , dWner tenant contractor) DATE'' l'. FACILITY TYpE r ' '� PCHD COMPLAINT # PROPOSED INSTALLER. "i t -r,, PHONE # ADDRESS' REGISTRATION /LICENSE # Cc tq 3 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 there pair., rr }1 1h0 tL:' :'!£ I, as owner,agree t6�the*conditions1tate on this form ,l , � 3 SIGNATURE �, �:' t r �. ;' TITLE ._ l'p ti DATE. f:F 1, the septic1hstallerr agree to complyyvith'the conditions of this permit for the septiosystem repair -• It SIGNATURE . . , c -' :: �'t4-T E =f 4, DATE. :. f �j (installer) .' Pr000sat approved with the following conditions- 1 . Procurement of any Town Permit, if applicable.: k 2. Submission of as'buitt 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 Taz'Map: number era. b. Location of installed components tied to two fixed points .. c. System description (6.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 designand 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 front the Department _ - INTFRNOf, I ISE.ANLV Proposal Approved 0?f Proposal Denied ❑ s c Inspector's Signature & Title Date Repair proposal is in compliance with applicable codes Yes 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Expiration Date No :.E7' Rev. 2/07 7�T RM -i � ww, i �m m Nw , _ �. mac.^{- m g�• _ .'.-„ I'sa y a ".#✓.+ AN Ross ` ra*ti'.y'r-7. J 1 T : r'c Y "�7 >' s'`�7'Mky'l• �. ad y�5•ay9Y !j! ,� _Y{ Gci ^ice �. lr - di rt'-.. .J �''_se5 -� _✓` r r y w f rt '. a'' . :. y.. �,ss ._ `^'r,.Y `'EAT Cyr •'"' -r '/, �.. tr 'P .a, .•:'�'. da. ` -; �,�yd ..yam ,y ��j ,y ,*' t3 ;«h AIR 'no Ph �i !- - �r r Af a+ {. I `'�. ,:�. -✓ r,..o ,M i a� � l c ' iC Pilo! } x 7 r ; j� }a r 4�t" g� ��f• j` r ask" MWINSUMON - i"`t �c nyy�t P T a n y x:c7e k' f�f 's+ i tyY ,c 4�#?� '-. r 1{`�.'y"i �� •k..c F,. ,`! ? t* .A �3 J 1 ti ar ." aS^` � � � -. �, i 7 ' S �r $7strt' `,�'; '` bt Z- rr^.•,.�>�->� R ('^ ��y �,r- -t`a- L g . qy= T S . d 1 , i.� 4' �F f� 1.4�y <•'b_.•�. ��1� �j,,,� '`1 f "� �°a„•"!a rd' IV xt. };,)..•c�,hyr, '� 7 .c-F, tys `\ • s s� k ".�,°�' �"-'" 'yc- r r1 � � � i� "1' ''}rs: il,S ��" t . �, � v •t3 ," r :« �t I E L 104 „�tl is i Local Guy Plumbing / Drain Services Inc. 3 -Finch Lane Lake Peekskill, N.Y. 10537 Tel: (845) 526-2471 HI 1T A cc '37 7 C- ox/c PUTNAM COUNTY HEALTH DEPARTMENT CD i i ' I y DIVISION OF ENVIRONMENTAL HEALTH SERVICES V PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR, . YES NO Internal Use Only ❑ EV Repair Permit issued in last 5 years a 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 ❑ Joint Review SITE LOCATION Lakc_L {��1��%21,i �f TM #93,9),- % " 2- OWNER'S NAME pg� MAILING ADDRESS APPLICANT E ANC Name & Relationship (i.e., wner, tenant, contractor) DATE 16 - & .,2& FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER 1176 PHONE ADDRESS l "�i G {C REGISTRATION /LICENSE # �C — /Vy i�S"%2 zv6elrirl oz/-04/ 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. CA ffl1i (1) WMI I A/A /1 /i. 119n PiIffzok is✓ 101f,&&, AriA? &,,u i ,.._..._ _._. .r�n��tt:� -; °� -mss t ��- �,�n,�.�-0'�':�b�:.t�t�'�-�°��c= ..� -._4 �-- •- -..��, � . - ..� rs;,.�� -�... ._ �_..b . J r P. taLt ��, G« ;a,�vide 'OLs �X" # -E� t� hek w I, as owner, or reported agent Oowner agree to the conditions stated on this form SIGNATURE TITLE DATE !L o6 Proposal approved with the following conditions: curement of any Town Permit, if applicable. y a. ubmission 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 number 3. System repair to be performed in accordance with the above proposal and conditions. Proposal Denied t Yspector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 a c 'S.heet a Y of `PiITNAM COUNTY DEPARTMENV F HEALTH` ' ES - SERVICDIVISION. OI tI Ik . FIELD aACTi - -VITY REPURT - -�ez" PVT►'VWI 'I%,t1G��` ann:S•iG� Street Town State ". Zip P ERSON IN CHARGE ��. ps✓1- /�or�i� ' �� /.7 � �< A ;: a P: > Name and Title FACILITY. TYPEDF Ps1 . j�C Tom.??- �k - F i ` c� AA cm i iv s v -. t T r r 4 r ,x n" aj :: l t a° Signatta d_ Title PCi12TrRF(`FTV T) RY• Y wledge recut of ths'report TC1RE ackno SIGNA I ":a; , Title, X414 By5 529 s�Dy (aye. b L l9 we// L a.-IQ Ci .�l a /0.65• N c3 v to ,N �0' h V Frv„r�r p °• . yam p`0 p awkvc �• 4 A/ SURVEYED & PREPARED BY BUNNEY ASSOCIATES ENGINEERS & SURVEYORS 155 KATONAH AVE. 929 MAIN STREET roflA V NEW YOiilC 1053 §.. >P_F.kKSKII,{:j_ NENF YOR_ y Oct? A T-1 N - --,I- N-C- -.N:!CAV 91 I rfvl A a P.O. Box 395 Mahopac Falls, New York 10542 914-248-6148 4s a 0 Sep)yc- }&nlr— i 8 (, ck ( I I-ed / i) A (co