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HomeMy WebLinkAbout4761DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.26 -1 -59 BOX 36 04761 T d JU IN3WJ-0Q03U Jll - P f)"jM---40F IEXIVI%M�t MLAMUR SERVICES 22:t7T NOW s002-oT-e33 OFFICIAL VSH ONLY SM.-LOCATM PHONE. OWNU.. kM I �r"*�-PIA'rijv L.%" ADY IOS-A-1 MALMO - .. . . I PERtM-B'I 71 PCHD Complaint # DATE �-,7 TYPE FACILTrY PROPOUDWSTALLER P PHONE ON# dag aq a WO). 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 DA TiL 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& z l �� DATE I abled 'ELSWLSH dbC:10 900ZIK q93 m <D td 134 �jj X C'D LO co O LO O C) r1i rX4 14or-.2sel, tai m 14wm da as fw! .4 Ill. IC C6 w LL 0 LL z LLI Z: F- CE a- LU Lake Pedo*M 1039 (US) 5234203 Tama of ftum Why al z TM MWN=ber: 9I.M-1A 0 u of AR pair CE z of-8 EjOkaois I. LU Inc. NY 10524 (945) 73"57n r LO LLI F- cu N 0 U) Ill. IC C6 w LL PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES .:p�'�^.'si _.:cta r r�ia•. .. �_'.�py_„t6�:�; «;.aix C'r_ ...�.'.e ,...r„ :dv^ �' �:r'�r PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR SITE LOCATION—'-t OWNER'S NAME_ MAILING ADDRESS OFFICIAL USE ONLY � - ) 9-0 � 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 _a 'r C +J i i Q q 1 Homeowner: Joanne South 4 Melnick Place . Lake Peekskill, 10537 1f 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. „ya y 3 Rochambeau Road Garrison, NY 10524 a' X. SA-; (1145) 736 -0571 .e is o P <4 —110 1 � P .e i . t III 4 to 1C)s "Cx I W- t I act 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 ) a. Ll �-- D `ice � � J 'age 1 of 1 el—i, 1 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: —&jty qvm..z,, X-04e-ldge,�,�,UL Phone #: NATURE OF COMEPLAUM (Briefly describe) lk Nt 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) lk Nt