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Home My WebLink About4770DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.26 -1 -73 BOX 36 17-2 ,it AA 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 r r� n, fl; a� d• 4• 1;. d; i �A s! 4' 4: 4. e• a 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 ^ ^