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BOX 36
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1■ - y�
04770
f PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.. ryYC;r.IS '.Q. - -. .n.r.GA .: T'� C .. �. :....1, .•i.+.::. '�. . 4..� .4l ... ♦ .e ...
Internal Use Only PERMIT•#
U L�l Repair Permit issued in last 5 years U t in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ L� Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION TOWN ��.Q�s�g`i.�l TM # 1—
OWNER'S NAME . 4A& V\- 4uNA*ta l PHONE # ,SJ VQAA
MAILING ADDRESS
APPLICANT
DATE
Name & Relationship (i.e., owner,
FACILITY TYPE
PCHD COMPLAINT #
PROPOSED INSTALLER PHONE # .(�O67b
ADDRESS REGISTRATION /LICENSE #
Proposal (include a separa—t-e sketch locating the hou e, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
I, as owner,agree A the conditions stated on this form
SIGNATURE (% TITLE DATE i4lo
(owner)
I the-septic instate agree *3 c Iy with the conditions of-thisnermit for the septic system, repair.
SIGNATURE ' DATE
(installer)
Proposal appr d with the following conditions:
1. Procurement of any Town Permit, if applicable.
2.. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilledyntil authorization to do so has been obtained from the Department.
7 INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
nspector's Signature & Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes ❑ No Z,
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Sheet (of
ofj- '.
PUTNAM COUNTY DEPARTMENT OF HEALTH
7 �s
-A-L-4 -A -I'CES
DIV-ISION.O.'C.ENVIRON-.M-FN.T- 1;E . TLU' =V.
FIELD ACTIVITY REPORT
AbDRESS: 77,/. &/1" �
Street Town, State zip
PERSON IN CHARGE
(lg TNTFRvTFx&TT). T)atp.
Name and Title
TYPE OF FACILITY:
FINDINGS: coif-fae4zor
Signature and Title
RFP()RT RF(,F.TVF-T) Ry:
I acknowledge receipt of this report: SIGNAT6RZ
02/96 Title:
APR-28-2008 10:41AM FROM-ENVIRONMENTAL HEALTH
f
8452787921 T-362 P-001/001 P-456
PUTNAM COUNTY HEALTH DEPARTMENT
0
THIS IS NOT A REPAIR PERMIT
PROPOSAL FOR EXPLORATION gF SEPTIC SYSTEM FAILURE
All information below must be fully completed prior to any scheduling
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
TOWN/44, TM 4
,a�����
PHONE #
PFiOPOSED CONTRACTOR/INSTALLER PHONE #
ADDRESS -4'd_%EC3lSTR ATION /LICE . NSE #
VJV
Reason for exploration:
0 failure to surface ❑ back-up in house 0 find limits of system for repair 0 other (explain below)
FOR COUNTY USE ONLY...,
Inspeotor's Signature & Title Date
Appointment Date: Time:
kly:excel:saptic
SEPTIC TA
10
r-
Alice krochnsl
►'11 Johnson St.cct
Lake Peekskill NY 17537
As built drawing for Putnam County Department of Health
Faxed to 845-278-79219-9-09
i
FRONT DOOR
A= HOUSE TO OUTLET = 18'11"
B= HOUSE TO SEPTIC
= 15'
C= HOUSE TO SEPTIC
= 10'
IJ= 11clUSE 1 U 5EP l K—'
=11'
E= HOUSE TO SEPTIC
= 1 C'
F= HOUSE TO OUTLET
= 10'11 "
NOT TO SCALE
t'
i�
t
T
t
NOT TO SCALE
i
DIY' 7'
G ter—
S. %]
R DRYWELL
A DIWIEkSIONS
V
E 5.
L
GRAVEL
covered with 8'x 8'
pressure treated timbers.
A= SEPTIC TANK
E= HOUSE TO DRYWELL = 20'9"
C= HOUSE TO INLET = 18'2"
D= HOUSE TO INLET = 12'8"
E= HOUSE TO DRYWELL = 14'
Si
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a�
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4:
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NOT TO SChLE
Sent By: MR ROOTER PLUMBING;
845 635 1173; Sep -9 -09 12:59PM; Page 2/3
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES '
,, :L�•..•.. r. _._- Pj .,'^f'._ y.z��. .. ..._ %_� -...- »._.; �. -. T_.- �...,`•a•. .•v.,. -r.i :::,._, r:... -'i .c., ]. 4=ywy'w, '-�_ -(�_ ..
ROP SAL FOR SEWAGE TREATMENT SYSTEM REPAIR • -"
YES NO Internal Use Only PERMIT !t '' 1 �r "' •`,:� t.L
Repair Permit isswed rn last 5 years ! dot in Watershed
LI Repair within Boya's Comers, W. Branch or Croton Falls Res. _ Dele ateC
I Repair within 2oo ft, of a watercourse or DEC- riWped wetianti Joint Revir'bv
SITE LOCATION TOWN '��1 TM ii (i •.•.f t•. -..� r'...Ii
OWNER'S NAME ` ct -
MAILING ADDRESS
APPLICANTS
�4.
Name b Relationship (i.e., owner, tenant Contractor)
DATE `t ,' FACILITY TYPE PCHD COMPLAINT 4
PROPOSED INSTALLER PHONE;y
ADDRESS �D Y, � —l�l�* � '" ��i REGISTRATION /LICENSE! V\,L
Proposal (Include a separate locating the hou&e, property lines, all adjao.ent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional ci pendincg on the
nature and extent of the repair.
I, as% owner,agree the conditions stated on this form j
SIGNATURE / •'1�.fc�-. -� TIT:,LE.`- ".�`�..:_
I, the Septic insta agree to coA;ply with the conditions of this permit for the septic syste+n ropair
SIGNATURE TITLE 1 DATE °` •,`� .�``�
(installer)
Proposal appro d with the following n ixir�n;
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicale shpwing(
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to rho ;turation at whir•h tha
wmpleted SSTS repair will function.
5. No completed work is to be backfilled pritil authorization to do so has been obtained from the Departmenl
Proposal Approved
nspector's Signature & Title
is in
INTERNAL USE ONLY .
Proposal Denied
es
Dade
Yes
ration Date
No .EI.,
COPIES: PCHD: Owner-, Instal er ^ ^