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HomeMy WebLinkAbout4462DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.15 -1 -17 BOX 34 jee -1 or I . Re 'kee; l L I ��� t, , f , ve 4pv I 04462 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR SITE LOCATION OWNER'S NAME MAILING ADDRESS Name & Relationship (i.e., owner, teaefft -, traetor) Ov, 91y "'W!� DATE FACILITY TYPE 2-- F,u..;J� PCHD COMPLAINT # PROPOSED INSTALLER Geoyt&rd i ¢- SOS —PHONE # 94 940 �s S ADDRESS Co 60-gl, Or &rfa-l+ A xi- REGISTRATION /LICENSE # P� 1J' G O 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. J (Z,o O LIJ r10 0 v,Z-(--,1n C �c�?1J�►�l' - =- fG�v►_�� C:t_iLLY f'►'c �►ytC� >d"�~� �i�� �'/u"� lij�v(,r�"���. +-,..y _ �✓l�L'!�. � /��..r •f i2<` � ©2 ��ic.J, I, as 4`wner,agree to the conditions stated on this form J SIGNATURE - �er s�1�� TITLE ®UJo K- DATE (owner) I, the septic installer, agree to comply wi he condi 'ons of this permit for the septic system repair !s _..SIGNATURE._.,.._ .�...� � .a, ..__ � ....:.� -� _. ��.C3yt,��- (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: /(L a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points o +� f7 �J 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 n' 4 completed SSTS repair will function. J�a 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. / INTERNAL USE ONLY Proposal Approved pector's Ignature & Title I is in compliance with COPIES: PCHD; Owner; Installer PC -RP 99ML Proposal Denied codes 11 /, 7 Date Yes Expiration Date ❑ No ❑ Rev. 2/07 Dec 05 07 08:56a Leonardi & Son Constructi FAX Date: 4 From: Louis Leonardi Leonardi & Son Construction, bac. Fax# (914) 736-9311 Tel# (914) 736-9010 To: Fax # q-� .2 2iz_L_ Pages: Z- (including this one) (� eq 1-914736-9311 P.1 ;7 7-, co r 4L., f -- %�, 7 .....� mss_ _.._G._�:��� ��� � �� , 7, 'Val S{f )A.1 i + I'V IA) V / --'-h i a�5(o� G__7 Zi.7L, ( -L o4 bo G00 KI* R Sf Pf VLF((ey As Built Drawing 3 0 Pefnu� A 63-6 Leonardi & Son Construction, Inc. Date: PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR 773 Name & Relationship (i.e., owner, te%Rt —, s�r) DATE FACILITY TY PE PCHD COMPLAINT # PROPOSED INSTALLER /-(f?0 &a.rC11 1 4- sop PHONE # ADDRESS Co Cetr Or &rf je a t i- 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. , , I, as'bwner,agrefa to the conditions stated on this form J SIGNATURE TITLE pttjoe-'' DATE I Z� O- (owner) I, the septic installer, agree to comply wi he condi ons of this permit for the septic system repair SIGNATURE D fi=r DATE l Z/ (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 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. Approved & Title INTERNAL USE ONLY Proposal Denied Repair proposal is in compliance with applicable codes COPIES: PCHD; Owner Install -dr PC -RP 99ML El < </d2� Date Yes Expiration Date ❑ No ❑ Rev. 2/07 Dec 05 07 08:57a Leonardi & Son Constructi a d 1- 914736 -9311 p.2 c - Leonardi &,Son Construction, Inc. Date: Pc c- q - o 6 Carolyn Dr. Cortlandt Manor 10567 (914) 736 -9010 T DRAWING Pr-I Leonardi & Son Construction, Inc. Date. 6 Caro , lyn Dr. Cortlandt Manor 10567 (914) 736-9010