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HomeMy WebLinkAbout4321DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.- 132A01 BOX 33 WE a ' ; I,N� 41 . r Ir i . i 0; oil _ flog , . 04321 PUTNAM -COUNTY HEALTH DEPARTMENT3� J �T DIVISION OF ENVIRONMENTAL HEALTH SERVICES :;P Lo-SAL FOR:SEWAGE`.DISP©SAL.SYS :EMI. P I YES N Internal Use Only O ❑ ❑ Repair Permit issued in last 5 years ❑ 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 OWNER'S NAME MAILING ADDRESS A967_K ,1arVXr1tf- Polo P-D . TM# 6AIr Pg r s J PHONE# APPLICANT •-Ao w h SL P PAC si:4t- T Name & Relationship (i.e., owriet, tenant, contractor) DATE 2 /4- FACILITY TYPE f f PCHD COMPLAINT # . PROPOSED INSTALLER 'I`� -8 wh l�9 ��-f} �;G� PHONE # ,; ( 1-k-, R.0 ADDRESS Z,L f , r(;�l , ; 0 5-7C 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 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. ■Il��fi MVA" I, as owner, or rep rted agen ofowner agree to the conditions stated on this form SIGNATURE L-f.Ain TITLE t- 6rc�`l� Proposal approved with the following conditions: 0 2. . Procurement 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 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 condition Pro osal Approved Proposal Denied spector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 I WKMIW. �MM, DATE z c 6 P- E ?r4 E s-- Pe 190 lyl 'F r" r 41- /*7m k C/fplc, +4 6,4 e- (-«s ig P, 4f- -T- tIP- C- 5 0 u S 0- r� y M' 4 gs�# * "e� a � r � _ , ¢, I I:; J 4 YS , A"-�xg AP } !F S �y ,yv.ety 3 gs�# * "e� a � r � _ , ¢, I I:; J 4 YS , A"-�xg AP } !F S �y ,yv.ety a L -..- El Sheet of _ .PUTNAM COUNTY DEPARTMENT OF HEALTH bIVISION OF ENViliONMENTAL HEALTH SERVICES " FIELD ACTIVITY REPORT NA MF: (�Al I Tel: ADD 'PqR, 10L )gkAM Street Town State Zip PERSON IN CHARGE OR TNTF_RVTF_WrF_T)-. Name and Titl71flC52w1k, TYPE OF FACILITY : S'S� FINDINGS: S I N S P H ­11) R! C l . Signature itl RFP0RT RFCF.TVRT) BY: I acknowledge receipt of this report: SIGNATURE, 02/96 Title: Rev. tp! LL, wo a A � E 7- le� Tu Nag /Q 0 -ri4 (H6 5 f4b &,,,) r ile ( , p1-6 . t I :c ,Z) I .-f-