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HomeMy WebLinkAbout4724DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.25-2-3 BOX 35 or i or INN 9. Ir No Nol. �IN No 1�rw, , UL 04724 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'ES NO' Internal Use Only ❑ Repair Permit issued in last 5 years ❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland 0 0 ❑ Not in Watershed ❑ Delegated ❑ Joint Review SITE LOCATION a ..._ vo I TM # OWNER'S NAME PHONE # MAILING ADDRESS —� ri - n, K, LEI �-- APPLICANT �j C -' I te-14 Name & Relationship (i.e., owner, tenant, ntractor) DATE FACILITY TYPE C-S PCHD COMPLAINT # 11 kS- jij ji._'r(o ce-I/ PROPOSED INSTALLER s C F�- I Fr f) ► - PHONE # b Yf- 7—t (- 9 �}( ADDRESS p ZA r t JZ-- REGISTRATION /LICENSE # Z I_ NCI 1 2S 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 reqistered architect. I, as owner, or reported agent of o n r agree to the conditions stated on this form SIGN RE TITLE Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2 9Submission 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 conditions. Proposal Approved i�/� Proposal Denied 4 & Title. Date COPIES: PC -RP 99ML Rev. 8 /05 White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) DATE V—/, "Deaty Calls" SEP-TECH Inc. P.O. Box 197 Stormville, New York 12582 -4 — 771 845-226-7606 r? 0, C- 5 C-- ('00 C-1 gekle— ?-El. Ae 30, F Cj F U-1 F �� CL- 4 �3 1 ,-. -1 'ICIS r Ca—e- re- - :7- �cz br% a� 4 �3 1 ,-. -1 'ICIS r Ca—e- re- - :7- �cz Sheet / of / PUTNAM COUNTY DEPARTMENT OF HEALTH FIELD ACTIVITY. REPORT A T)nR'P,,q,1R: ci �- �-� v. Street Town State Zip PERSON IN CHARGE no , - r Date- - - - OR TNTF-RVTFVrPn-. 41 / ) r& ;rgcff :5j Z< Name and litle TYPE OF FACILITY :l r—> . 5S T FINDINGS: .7 43 ev- it.T 1 S rb rb L Lib I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Rev. d&WS ZF-LL-ra—FOr(5 A S reW- PLIO 1v A 44 .7 43 ev- it.T 1 S rb rb L Lib I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Rev. Ividy Z4 ut vl:�Up �-AX SENDER 1 555-555-1211 p.2 S-OPJECH ha.. P.O. Box 197 Stormvill . e, New York I m 2582 845-22- -9771 845-22 -76A6 D b6. C- 5 e— PO C-1 Xc T,K F C, �= -7- 0— we-w% -p" T— a o iviay u u l :Lap F-AX SENDER 555-5 p.1 IlDooty calls" y SEP -TE.�CH .: Inc. � .... %.;.�'7� '•r �. .tt••�Nli'i� =: rVR�','Y'�::s iwa. " .. �v�'�ra.oas— �.'+ -i +fa- .. r�.'w ....,:,� �e. i. ,.v•'.:y P':O:rBox'i�� =y �tomivilie; Ne�i�`Yor�C�I�S��`" 945-221-9771 ' 845 -226 7606 JOE DIGIT... HI JOE..... PLEASE FIND ATTACHED THIS PROPOSED SEP'T`IC LEACHING REPAIR FOR 60 CIRCLE DRIVE - TM # 91.25 -2 -3 .... AND ADD IT AS AN ADDENDUM TO THE PREVIOUS PROPOSAL ENTERED IN APRIL. PLEASE CONTACT ME IF THIS IS APPROVED THROUGH JOE P, SO WE MAY BEGIN WORK IMMEDIATELY. IF NEED BE, I WOULD LIKE TO PICK UP THE PERMIT, SO WE HAVE IT IN HAND. ANY QUESTIONS, PLEASE CALL ME AT 845 -242 -8658 THANK YOU! RICH aan SE A -T ECH Inc. �,•..,�� _ P.O. Box 197 StQ rmville, New York 1.25.2 yy - Y Y.�+.r tttii.ZM�+ :t �j']�n wi ,�1�i y .r f-•� �. q� .`.P: —.� Ts�'. ... _ IS�Py • vPt _.•1nr f y '�..e.'�� . �$4� -'M -9771 845- 226 -7606 TA 5 C Go 2 c S- - 2- - 3 T I ® LO c<< A 0$. C- C'.0 y I ® LO c<< shect of PUTNAM COUNTY DEPARTMENT OF HEALTH A . 'SE L. -IJU FIELD ACTIVITY. REPORT T,J A Tel: SS� t16Y 61,7 "41 'Ile AT)T)R 16 . Street Town State Zip PERSON IN CHARGE Name and Title TYPE OF FACELITY: c- r�5 P4) iZ FINDINGS: el'11 3 / 0 7 o 41)E�vr am, E, (icilis' X15 44 VC, S,8lc IA✓ A-0&4- r, W J1 1-7 66 0 %,Ca;5' /,i/ /V-,r or-- Avlo Gull1jr-,- Z/sl- 02/96 Rev. Sheet of PUTNAM COUNTY..D.E.PARTMENT.OF HEALTI FIELD ACTIVITY, REPORT T,JAVR: 9 I-1 LL—.– �— Tel: -- Vr' I �Z 1,& 7° A– TO ADDRESS'. (,4�70 09U9- Aj Street Town State Zip PERSON IN CHARGE nR INIF-RYTEMMIni rhtp.. 13-1-07 Name and Title TYPE OF FACILITY: :22W.5-3rs e-epfix FINDINGS: J #0U59 -'j*Q f;_ _; Signatur Title RFPORT'R C-FTVET) I acknowledge receipt of this report: SIGNATURE; 02/96 Title: Rev. E__, Sheet of PUTNAM COUNTY DEPARTMENT OF.HEALTH _ 1 + FIELD ACTIVITY REPORT AT A W A-0 . �A�s� Tah r 4/189 4 T,)np F Q .Q ; 60 '�-�/ !�•-L� k - ;E0 � 1 A ! l /41 01119� 1101 Street PERSON IN CHARGE Town Name 'd Title TYPE OF FACILITY: /k SST.S State Zip FINDINGS: 1 fV s a0e` fl o,,) Z,( 4oZ zxW 6nooJ�- 90 I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Rev.