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04739
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
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FIELD ACTIVITY. REPORT R , I lG�� °f p"' y '
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Street Town State Zip
PERSON IN CHARGE z -71V
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Name and Title
TYPE OF FACILITY: 7/,D,
FINDINGS:
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I acknowledge receipt of this report: SIGNATURE:
02/96 Title:—
Rev.
YES
El
El
SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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40 _ . rInternal Use Only
1 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
i12Rdi �.lake?ee�ska1!.lV/1r�,5
OWNER'S NAME
MAILING ADDRESS
` APPLICANT
❑ Not in Watershed
❑ Delegated
❑ Joint- Review
---► Name & Relationship (ile., owner, tenant, contractor)
DATE ' �(� ` V FACILITY TYPE lb -� If PCHD COMPLAINT #
PROPOSED INSTALLER �eCZi�IY 1 Ala PHONE # �4) 71 � 40 1 D
ADDRESS 6 REGISTRATION /LICENSE # Pr, —S o
C`0VV0Vtol 1` CW%.., NY /056.7
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 260
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 ,gr registered architect.
�F /U67 f" I �,r_,r, f �s d,,y .,Gr o. �l�1 S 4.�z l ���:�+�r. r5 /r.u✓
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE TITLE DATE
Proposal approve 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
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 cond! tb
Proposal Approved Proposal Denied
A
�! ( 10A. ,4. , `5 / /y C)/u 7
LIns`pector's Signature & Title( Date t
COPIES: White (PCHD); Yellow (Town BI); Pink (installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
MA
AnnRF ,qS: 112, �L�L����G►.� � � Vr
Street Town State Zip
PERSON IN CHARGE r�
nu TATIMID V \7 TR Mn.
Name and Title d
TYPE OF FACILITY: S} tic -mA
FINDINGS, �- 1 %t' 2.0 r
(IAL'
2/0
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I acknowledge receipt of this report: SIGNATURE;
02/96 Title:
Rev.
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPA
`�. , . � �. ;.t.:o'C.°• •�' ... �.1.. �,r • � f� ..... -==i •.. =� a .n�::::'`' „= '�_'....;�..a,�,p,'t. �.�: r:.`;.,�vnt'• G...w � .... ' P�C..,�y, r,'_ ��/��
YES NO / j Internal Use Only
i/
-_J Name & Relationship (ile., owner, tenant, contractor)
DATE
6
,
Z�' FACILITY TYPE j�Ip' jPCHD COMPLAINT #
PROPOSED INSTALLER Lei t PHONE # 401 p
ADDRESS REGISTRATION /LICENSE # Pr, 0
CoVVOVla MCWVT.i NY !0567
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 r registered architect.
engineer
6k Q,� A -1 J fo -) a4lo'n <0ok- 17 "O r w
Xi
I
I
I
I
i
I
I, as owner, or reported agent of owner agree to the conditions stated on this form-
SIGNATURE TITLE
Proposal approve 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
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 conditio
Proposal Approved Proposal Denied
A014 '5 -7 //0/ 02
I pector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
E
❑
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 R@VI @W
SITE LOCATION
J� e![ iouArook ?ekskill 10,5
—1-2
OWNER'S NAME
PHONE #(
MAILING ADDRESS
p k, 9irm
1 _
APPLICANT •ae.x�n,(d
C� r kIid
-_J Name & Relationship (ile., owner, tenant, contractor)
DATE
6
,
Z�' FACILITY TYPE j�Ip' jPCHD COMPLAINT #
PROPOSED INSTALLER Lei t PHONE # 401 p
ADDRESS REGISTRATION /LICENSE # Pr, 0
CoVVOVla MCWVT.i NY !0567
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 r registered architect.
engineer
6k Q,� A -1 J fo -) a4lo'n <0ok- 17 "O r w
Xi
I
I
I
I
i
I
I, as owner, or reported agent of owner agree to the conditions stated on this form-
SIGNATURE TITLE
Proposal approve 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
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 conditio
Proposal Approved Proposal Denied
A014 '5 -7 //0/ 02
I pector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
E
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on
,;F&4rL-o SMCIPF- Tel:
112 Aortowsua, f4 00,
Street Town State Zip
PERSON IN CHARGE
OR INTF.RVTFWPT)-. 7/2-0
Name and Title
TYPE OF FACILITY: 5F,,P7
10CX . AIIV95
FINDINGSZO,;N t 2,oD
OL,
T/vo
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I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
-Rev.
RapidForms i- 800-257 -8314
PRODUCT, 11 ",
}p y rage rvo of rages
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t +C?;ii+'� « _ w .rof,.m ?It G°-" rc1.':�I ;p i •o�.'•i;. -, ^'w• ^y.n; ..r�Aiea..,�.. -. •.. f_ ._. •l ..:. `•.� - ... �..� =C�J '1 °. �_ ,�f; ir. ti:�+n�i
LEONARDI'& SON CONSTRUCTION, INC.
OWNER: LOUIS LEONARDI
6 CAROLYN DRIVE o CORTLANDT MANOR, NY 10567
(914)'736-9010
LIC. #WC- 3112 -H90 a WC- SEPTIC LIC. #00067 o LIC. #PC -560 (CERTIFIED)
PROPOSAL SUBMITTED TO
PHONE
DATE
STREET
12—
JOB NAME
CITY, STATE and ZIP ODE
JOB LOCATION
ARCHITECT .
DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for:
_........ _ .... ...._ . ..... .......................... _......................._ ............... ..............................__............. ....-_............ ............ .......... ........... .................. ......_.._......__,,._ .'... ...._ ..l..l. -l.._ ...1.5�-...._....:. �.:._..
_ .................................................. ......._..............:.......- ........_ ............ .... ...............................
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_ ................................_.............-...................._......_.......................................... .......................... -.--- .............,.......... ,. _... ;.._._ ..... ..... -!....
I _.._...._._..._......._.-....._.._.................... ..... ........ .......................... ..._............... _...._._._...._..._............ ......_.................._....._..._............__..............................._...._....._......_...._.........._.._.._....._............._...............___......._........_ _..........._..._........_w..._
_..........._ ................. ............._...............5. - ..c - .. ..........�>.VA.Y........4'0., ....._ -1 ...:.. ®.. ...... ....... - ,�......__..._._.._....._...
......................._.._.__..__......__.._........._.. ..._....._....- _...._.......... �� ...._.......c. ..... I . . .....:......:1.. -... .................. ...__ ........... ...... ........ .._ ............... _.. ....__ ....... _...._._......_... _ .................... __- __ ..... _........
_ .......................................... ..........._.........._............................... _ ..... .................................... .........._................ w................. ............... .................. .......:............................. _......_ ... _ ..... ..................... _ ................ ................... _................................ ..................._.._ ....... _
PLEASE NOTE: 'SYSTEM LONGEVITY IS NOT GUARANTEED UNLESSDESIGNED BY A LICENSED PROFESSIONAL ENGINEER!
'TANK TO BE PUMPED BY OTHERS AND PAID SEPARATELY'
*NO LANDSCAPING RESTORATION. OTHER 7HAN GRADING D °
Be PrOPOSE hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars ($ ).
Payment to be made as follows:
A FINANCE CHARGE OF 114% PER MONTH WILL BE ADDED TO ALL UNPAID BALANCES.
CUSTOMER IS RESPONSIBLE FOR ANY AND ALL COLLECTION FEB.
All ON.
All material is guaranteed to be as specified. All work to be completed in. a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorize
Signatur '
Involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tomado and other necessary Insurance. Note: This proposal ma� be
withdrawn by us if not accepted wdhin
too.
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