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HomeMy WebLinkAbout4586DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.06 -1 -21 BOX 34 IN �. ir ■R��J J go ', ; , � 6 .. 4 j , r :, = ,. red. J6L. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPA... Y NO Internal Use Only PERMIT# ,� °-G�h(o —! —7 Repair Permit issued in last 5 years — TnlG VDelegated ot in Watershed c3 & Repair within Boyd's Comers, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION `� ��cca�v cz � TOWN//%2�w TM OWNER'S NAME ��r•,.cPAO L, /Z--/ PHONE # MAILING ADDRESS APPLICANT Mill ' Name & Relationship (i.e)-owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED IN TALLER S/ j ,,, s _ K( PHONE # ge ADDRESS 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 qad extent of the repair. I, as owner,agree to the conditions stated on this form SIGNATURE . ,. / TITLE DATE / / CJ (owner) I, the septic in alter, agre , o comply with the conditions of this permit for the septic system epair SIGNATURE,, �3,- r,./(� TITLE DATE y lx)v (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. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ )�),( W46/i �/// nspector's Signature &Tifld D e Ex ration Date Repair proposal is in compliance with applicable codes Yes O No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF EN VIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT Street Town State Zip PERSON IN CHARGE OR TNTFR VTFWF.D-. T)atP_ Name and Title TYPE OF FACILITY: FINDINGS: y TNCPFCTQR' Tr' Signature and Title R FPIIR T RFC- FTVFT7 BY: I acknowledge receipt of this report: SIGNATURE: 02/96 Title: F � PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use PERMIT-# -1-')- 4 10 Ll EIJ /Repair Permit issued in last 5 years I_1 >Mt in Watershed ❑ V Repair within Boyd's Corners, W. Branch or Croton Falls Res. Lill, Delegated 1:1 Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT TOWN (% TM #S PHONE #py� ? t- Name & Relationship (i.e., owner, tenant, contractor) DATE It d. va FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER O U4 t, ; Qr" (o "7- PHONE # ADDRESS At/t_ REGISTRATION /LICENSE # ' 7 r 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 ­4 _Z 46,. I, as owner,agre the conditions stated on this form SIGNATUR TITLE DATE 1 O I, the septic installer, agree to the conditions of this`pefmit for the septic system - repair SIGNATURE <1 TITLE . � DATE _)/l S O T (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. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ t / Inspector's Signature & Title D to� Expiration Date Repair proposal is in compliance with applicable,codes Yes lam" No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 i �•i,.b_ -�-, :r', �, �,. _ ri �it�s�b�.'w-�^..wLa: uta�v.ti�� ��tr'- �i.:�sR'+�c+'ti:'�a-a°-���s�a -a .vry i�ai 34 "!Columbus Ave Putnam Valley N.Y. 10579 914 -760 6344 Flannery IM-85.6.4-21 Date 7/15/09 9' Taconic Gate - License # 113 7 Putnain Valley N.Y. 10579 Replace existing metal-tank with 1000 Gall on concrete tank. i Al 21.0 :B_1270 @.