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HomeMy WebLinkAbout4254DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.82 -1 -10 BOX 32 No rL � Lm r.; -= 04254 TVL �19a . le"h c PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES W� Internal Use On G PERMIT 1'3S� 0i4S Z U pair Permit issued in last 5 years LI/IVot in Watershed ❑ . ©' Repair within Boyd's Comers, W. Branch or Croton Falls Res. 13' Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland Ji5int Review SITE LOCATION 04- X of VF V IW 5' c'v TOWN Y'y rNd-r-i VA-Ckr y TM # P3, P?- OWNER'S NAME P14 T/z t c, k (° if W (' V 6 14 PHONE # 9/Y,15-2-3 %f MAILING ADDRESS 4*sl "TCH W5'v ST- L k a e i�Sk t I ( es-3 APPLICANT wmt o q ' Name & Relationship (i.e., owner, tenant, contractor) DATE h L'L I D FACILITY TYPE 9�15-S PCHD COMPLAINT # 9r�F Sr77 moo' PROPOSED INSTAL ER �irJ1L�fZ�}rrL� PHONE # b-VS'.f'26 " 2 j J- ADDRESS � E IE TT;:; 'REGISTRATION /LICENSE # Lo Y' 3 Pro osal (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. reoair. I, as owner,agr.ee to the on this form SRszgI4 Al-Z, -e-J4.£-Q SIGNATUR TITLE `7 w 'z' DATE 9 (owner) I, the septic install r, agree to comply with the conditions of this permit for the septic system repair SIGNATUR rz,. TITLE 4(45WT DATE 1 I mss. /i r (installer) 14 r Proposal approved with the following conditions: s 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 Eg" Proposal Denied ❑ Ae- Inspector's Signature & Title Date / Expirati Date Re air prop osal is in compliance with applicable codes Yes No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/01 Sheet ( of_� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT A DDR Ec c _ Street Town State Zip PERSON IN CHARGE nR TNTRR VTFWPn-. cTZ-r TbtP' %Z 2.z T h O Name and Title _ TYPE OF FACILITY: S sTS I I/,2 5�,e !/7. Signature and Title ` RFPCIRT RF('FTVFn BY: I acknowledge receipt of this report: SIGNATURE: 02/96 Title; C of a Q. f t INGT NORM ST F ; � ST PARp . � .. CO w' a Oto37 XI ° 3 20 W J °R w Q �O �Pp zf_ , I D f �+ ♦^l Q o v m Z. WI WN G4r Q� i t _ QO Q dv w v J J DR 3 t o PylpsPp1N y O ° J tt r, i SKY LA, SLEEPY t to R v O 4♦ yP J O E;, ;. 2 to rtt 9� utnam F MCH� ails ' = -° , ^ W ALLEY CT W 06P 2 �� a P� J HN r� a Y E MS Y Q Z OJDT a O a x _ P% P� Q RD 9 P a a ALLEN Rp O o J z m J W 3 U VV G w * RD o ' Ho o'�'� ohegenj Lake ��' �1 / "T, 'S-3 2 rmlw��� It _ ;2-01 Th 932 ar�.[� tZ C14xa v c4 04 P,, ; Aft m Va 1,�.� Y LixE Pk t (� N,. "7, (os' 3? El, ts- p 6,595 too � .�► o N' . r_ . ( l A V 1� 491 F.. SITE LOCATION_ OWNER'S NAME PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0 T 70 WSoOY , l OFFICIAL USE ONLY TM# R3. 92- °- I / 0 I�{ PHONE r 7-t ^ / S%D� MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE 4/10 PROPOSED TYPE FACILITY PHONE ADDRESS ;L G,,f w,*, fu- A LK K GISTRATION# Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of %op3ssa fr<m licensed professional engineer or registered architect. PXIS'TiNG @Gt s.� 1, as owner, or eported agent of owner agree to -the conditlo "ns!-_stated oh`tthis`form � SIGNATURE TITLE (O G 1 DATE Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved L/ Inspector's' Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML q /J7 �� 3 DATE