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HomeMy WebLinkAbout4846DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.10 -1 -24 NOT ON DATABASE Ll a J.-6 ir I lir-m -j Ed M-5 I— %Tr I it 03019 Shcct of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL. HEATLH SERVICES FIELD ACTIVITY REPORT NAME: /sYiO� Z CIA TPI : 14& La /l,G 5ko it �P- Street Town State Zip PERSON IN CHARGE I )�vv] ? ),A- I Name and Title TYPE OF FACILITY: FINDINGS: ;2..7 ' .Yace Jvnatl m,., �m.x d/41 s�2aA /M -jM // 5�cm�r.C� r -` do-e, 4' ®4 Signature and Title R_FPQRT RFCF.TVFT) BY., _ I acknowledge receipt of this report: SIGNATURE; 02/96 Title: Rev. Shcet—�—of T PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLII SERVICES FIELD ACTIVITY REPORT ATITIRF.C.C: 146 1ot ke- `jlytnPe?i, PU,yiJ v a/ 1,� Street Town State Zip PERSON IN CHARGE Name and Title TYPE OF FACILITY: I* EA FINDINGS: �. l.51)e Q t✓i l� 5o(�` p o 4 A 4 1 0� i; N,-- e coy. 8c: av►c4 4-fee- cotes 8 �!7 Signature and Title RFP_ART RFC'.FTVFT) BY: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: Rev. PUTNAM COUNTY HEALTH DEPARTMENT CJ DIVISION OF ENVIRONMENTAL HEALTH SERVICES .ta" I� PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use Oniv PERMIT # / l�. f/Y .) f Li Lz%yl Repair Permit issued in last 5 years Le ^t 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 Review SITE LOCATION /0/6 L TOWN of M # OWNER'S NAME 'Z Z O PHONE # MAILING ADDRESS 0 i-1; APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE IT �� PCHD COMPLAINT # PROPOSED INSTALLER j # f'�S�'��'�': 1.O// ADDRESSj ,(11i�9,2 �u'�✓✓ / X b REGISTRATION /LICENSE # C -.-* C /4 A-0i®J, Whhouse, Proposal (incllui1,e a separate sketch cating property lines, all adjacent wells within 200 L C��( Z feet of repair and the location of existing and proposed system) I i NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the Wair. 2z'x-AC, t l %t i G�l °7�® �.� i_ n �mt '� ,., �r 11? ,LI.� ,c.� rq 5 © e—cte-Lj c '® I, as owner,agree t the cond7%KTITLE m SIGNATURE O CJAI- A.- DATE (owner) -- I, the septic ins;41 er,-a %e to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE p(„1 �/-� DATE & (installer) Proposal approved 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 backfill�d until authorization to do so has been obtained from the Department. C INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ Inspector's Signature '& Title S Date Ex ' ation Ofate Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 w 'Lake Tibet., PU ing -Swet 1, A 7, -7, .7 - 9,.fflk, y 21 0111"T A In _`.. , Z, Rest w l JA 10 r - Pq�,,�T G. Pa % cr. Tennis Gi DWO no 7- 0 ce so S Bryant Lx nw 30 -2mw)- gf- ce P.O. 30 iL Clear Pool In 21 'Club kjF�-- Swv� " payrettPO I tia, ,—,Lockwo . . And ('LOng Pond: I N r :, 4 Lake h vac Canopus Island 33 r