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631- 589 -8100
91.26 -1 -59
BOX 36
04761
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f)"jM---40F IEXIVI%M�t MLAMUR SERVICES
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OFFICIAL VSH ONLY
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71 PCHD Complaint #
DATE �-,7 TYPE FACILTrY
PROPOUDWSTALLER P PHONE
ON#
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NOM- 1q;* mun be in SAM'WAtiOU and of == tp as %*W-owep &qxnd q0M.Difibrat location
may-mquin submittal of proposal from fi
Mw pwwdow evocer or wgiftw arcwtip't
Lasoww tied t Of Owner agree to the'corAitions-stated on this form.
SIGMA TU
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Bnaw-Amand 3ft the fou2 n ng God"OL
1. Procurement of any Town permit, if applicable.
2.
SWM*Wm of as built mpair dock in 4ifim Aowmg;
L oww'sname
b. Site Street Nam, Town and TAX Map number.
C. Location of installed compow* dd to two fted points (e.gjwuw =m).
d. System description (e.g., 1250 gal. Conamete septic tank, three precast & dim X V deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approvcdl—, /—
wvemes sipNture & Title
COM: WWN (PCHD)-, Wow (Town 81); Pink (VphcW)
PC•RP 9M&
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION—'-t
OWNER'S NAME_
MAILING ADDRESS
OFFICIAL USE ONLY
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PERSON INTERVIEWED la-moeu� --�-.PCHD Complaint ame e a ns ip i.e., owne , tenant, etc .7 —
FIX11�
TYPE FACILITY
PROPOSED LLER INSTA P PHONE
ADDRESS ;3 Re. RA 1, Gecm�rN., GISTRATION #� (�
Proposal (include sketch locating all adjacent wells):ivu' \ os;�J
NOTE: Repair must be in same location'and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
er' b po tea ent_of.o: per gree'to'tlie cosid�itti-ons. sfated on :ih:s for : -
SIGNAT , URE TITLE 1 r0,a !�,,4 Ce
Proposal approved with the foll wing conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
DATE lia
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6 deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved,
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
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Homeowner:
Joanne South
4 Melnick Place
.
Lake Peekskill, 10537
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3
(845) 528 -8203
Town of Putman Valley
Tax Map Number: 91.26 -1 -59
Deseuipfaon of Repsanu° to System:
Installation of 8 Infiltrators w /Gravel
ItMaWler:
A
Philip Leonforte
Precision Excavating Inc.
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3 Rochambeau Road
Garrison, NY 10524
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(1145) 736 -0571
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Homeowner:
Joanne South
4 Melnick Place
Lake Peekskill, 10537
(845) 528-8203
Town of Putnam Valley
Tax Map Number. 91.26-1-59
Description of Repair to System:
Installation of 8 Infiltrators w/Gravel
Installer:
Philip Leonforte,
Precision Excavating Inc.
3 Rochambeau Road
Garrison, NY 10524
(945) 736-0571
"D
Complaint Information
.- . _.04.: 013 Q.:.t3 Cprrplaini�R v 1(6rts _ -:R r 8 .� �_ -
.y_...... _., .� "0,-�,..._. •adr�.•. �gJ.c -e.. `:— c.�o-.. = ';E;s. ,.1�= :r�C>�$!'.:- ,.,;:+.::�'s�8'
a ...aR" r may: .m
Rcvd via Telephone Time Received Assigned To Hedges, William
Anonymous
FirstBruce Last Knapp
Address 33 Pecoho Road
City Lake Peekskill State NY Zip Phone 845- 526 -0403
ungmraource or tomptami
Origin /Source JULIAN SELT
Address 4 Melnik
Phone 845 -528 -8203
Location Town of PUTNAM VALLEY
Operation Type Complaints not associated with a 6HIPS Facility
Category A condition, action, activity, place or area that is anrn
Complaint - General
Facility Address
Sub -LHU
Risk Level No risk assigned
. Grllp aillE
Nature of Sewage exposure Complaint Date
Complaint Status Resolved Resolved 3120/12
Description ActionTaken
Septic leaking. 2/7/05 -SITE INSPECTED SSTS
3/16/12 FOUND IN ANOTHER FILE
3120/12 -PER REPAIR PERMIT #R -19 -05 APPROVED
2/14/05 AND AS -BUILT SUBMITTED 2/28/05
THIS COMPLAINT CAN BE ABATED PER MIKE
:.....,. :..:. -. -. - ...__- :..._ ...- BUDZINSKI,.DIRECTOR OF- ENGINEEKING 3 /20/42.: .:.r_. _•_:::
Page 1 of 1 Date Printed March 20, 2012
Complai ni Information
Log # 13-0549 Complaint Received January 06, 2005 Received By Walsh, Christine
Rcvd via Telephone Time Received Assigned To Hedges, William
Complainant (Person Making Complaint)
❑ Anonymous
First Bruce Last Knapp
Address 33 Pecoho Road
City Lake Peekskill State NY Zip Phone 845 - 526 -0403
— origin/Source of Complaint
Origin /Source Neighbor o a
Address 4 Melnik
Phone
Location .
Operation Type Complaints not associated with a eHIPS Facility
Category A condition, action, activity, place or area that is ani
Is
Complaint - General
Facility Address
Sub -LHU
Risk Level No risk assigned
-Complaint
Nature of Sewage exposure Complaint Needs Investigation Date
Complaint Status g Resolved a�
Description ActionTaken
Septic leaking.
7 )
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'age 1 of 1
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Date Printed January 07, 2005
�I
First/Last Name:
Representing:
St. No./Name: 33
city/St./Zip:_
Phone #: C)
ORIGE14 OF CONTLAINT:
Origin:
St. No./Name:
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Phone #:
NATURE OF COMEPLAUM (Briefly describe)
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HOW.
RECEIVED
LOG NO.: LOGGED BY:
DATE COMPLAINT
RECEIVED
BY:
RECEIVED:
I.E.PHONE, .
LETTER, ETC.:
�o�
zq � tcrr_t,_. I
First/Last Name:
Representing:
St. No./Name: 33
city/St./Zip:_
Phone #: C)
ORIGE14 OF CONTLAINT:
Origin:
St. No./Name:
—&jty qvm..z,, X-04e-ldge,�,�,UL
Phone #:
NATURE OF COMEPLAUM (Briefly describe)
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