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HomeMy WebLinkAbout4739DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.26 -1 -2 BOX 36 ME . . , -: . ill JIM .,,,.� . I A - L �. I � . 04739 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH -�WDIV-1,SION-OFE-NV-IRONMENT,,A-L--.HEN-.L-�T�H'-SERVIC-E-S'--° FIELD ACTIVITY. REPORT R , I lG�� °f p"' y ' Tel: AnnRFq.q*,' z),t Street Town State Zip PERSON IN CHARGE z -71V 71a7 V 4 / (-IP TNJTPRVTPWPT)-- :3� T)nta- Name and Title TYPE OF FACILITY: 7/,D, FINDINGS: c, -rA 114 6 4 lis-o Avc 74—,Vk r-�Msl-r--ab or colica-cro) - Xvo Awo 5tl0u� X6 57bur,- L150C, IVC-- P17- 9N4,. W , , W 4NO) o- 77/'9- S)lAf E7 /'�Wox /0:1 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 .•-CJ •- �••<���':GO,..�.r sa.b �u :$' >._ �¢i»�ni.n�':: +`oi r..Xw�..'`•n2r'?iv..= _.C�'9'V On� 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 -1 .)V I acknowledge receipt of this report: SIGNATURE; 02/96 Title: Rev. Q•(-i u (:fx4. I nL . it- +o Ike- rt,?-,f I'V2 1,14. 4k- A--,ew IC;)L*)C) C, ILL No0scL' , TV n kc- I -lip roo.E, ZO CwA, 1-7-DA. Q•(-i u (:fx4. I nL . it- +o Ike- rt,?-,f I'V2 1,14. 4k- A--,ew IC;)L*)C) C, ILL No0scL' , TV n kc- I -lip roo.E, ZO CwA, 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 0�1 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 I �, IV) �xt& I acknowledge receipt of this report: SIGNATURE: 02/96 Title: -Rev. RapidForms i- 800-257 -8314 PRODUCT, 11 ", }p y rage rvo of rages . t}�, � —+� ' r f7.�: • .i -`b`1 : . �.p = .`.ate.. �- 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�-...._....:. �.:._.. _ .................................................. ......._..............:.......- ........_ ............ .... ............................... • � ®use ..... .............. ._ ......... ............._. .... �....::...,. ::._...___...:...._.... ..... _ __- �.,2. /vim j \�...... �_..�_.p. ............ r .............. ..._...- ..�:........ ....: -....7 :........ ._.............................. ................ ..._.... ........._......._- .......... -. T�11�� .................. ..... .............. .._. ......_..... _...._. ....._... ................._. ...._.......................... _ • V M _ { a S r e f I _ ................................_.............-...................._......_.......................................... .......................... -.--- .............,.......... ,. _... ;.._._ ..... ..... -!.... 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. b- C-20 picr.-d i PL. JG�-&O ull 4-k Oty\.ev- CW4sf l-,, sf r -t --, C-L, -- t I5 0 -�.�i— a.c��� k4t�, 4i Z-O +, auk v •r / t` Y- lq ) ALI- a ��t �t. Pv fi k`. .,�