The URL can be used to link to this page

Home My WebLink About4856PUTNAM COUNTY HEALTH DEPARTMENT DIVISION-OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIF Internal Use PERMIT �J r t -J i �J U u { Repair Permit issued in last 5 years L7 ,Wot 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 OWNER'S NAME MAILING ADDRESS APPLICANT q7 I u VfAaN VOA- , (e�, TM # 16 : 8 1 — ( �.v-1S cis ka ivP_r uCr S01F Z PHONE # 9# 7-60 l06,T_ 0,10W 170 � V at (&AI Name & Relationship (i.e., owner, tenant,A0WCCto9 DATE f—_! —� FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER L� rr(c;- �oct.�l r��t" " ->t�.. PHONE # ADDRESS IV 344 , AwREGISTRATION /LICENSE # ( Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 v 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 --*. - —4 ...,4....4- -4 LL... _......._ I, as owner,agree to the conditions state his form e SIGNATURE TITLE DATE l f �Pt (owner) I, the septic installer�ya7grt co mp ith the conditions of this permit for the septic system repair SIGNATURE TITLE �r�� 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 backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved ❑ Proposal Denied ❑ ,4. f ) , I -�% ZE- 3 O o nspector's Signature & Title Dat� iratio Date ,Repair proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Page No. of Pages Arreptanr a ®8 PrOP0901 —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as ' specified. Payment will be made as outlined above. Date of Acceptance: Signature LEONAADO ti SON C ONSTRUC TOON9 ONC . OWNER: LOUIS LEONARDI 6 CAROLYN DRIVE o CORTLANDT MANOR, NY 10567 DAY TIME CELL (914) 980.31554 OFFICE (914) 736.9020 LIC. #WC- 3112 -H90 o WC- SEPTIC LIC. #00067 c, LIC. #PC -560 (CERTIFIED) PROPOSAL SUBMITTED TO rt" ef, IEV~t r(l ("o PHONE DATE STREET V7 (6) W A ` JOB NAME CITY, STAT and ZIP CODE JOB LOCATION ARCHITEOT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................................................... . .......... . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . ................................... . . . . . . . . . . . . . ............... . ............ . . . . ................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................... .::.. 5, 1... e ......... .............................................................................................................................................................................. ............................... ......................................................................................... ................................................................... ........... .......:........ ...... ...................... ....... ..................................... ............................................................ ......................... .......................... .................. .................. ............................... ............................... ......... ................................................................ .... ............................... ............. .......................................... ............................. I.....................f.....: � ...................... . . . . . . . . . . . . . . . . . . . . .... ................. . ................... . . . . . ........................................................ I .......................... ....................................... ............................... I,...d..s .......... .......... . k) .....t ion..:....... .... .0 �... c, . ............................... ............................................................................................................................................................................................ ............................... ............................... ...................... ........................................................................................................................... ............................... ................................................................................................................. ............................... ........... . -, .................... .1_[ ...W.............. .................._.......................... ............................... _PI.EiMNOM . ............... SYS 7FMLANGBM,.IS.NOT.GUARAN.7EM- UNLESS. DESIGNED. BYAWCENSED .PROFESSIONALEVGINEER.° .............. ........ ............................... 'TANK TO BE PUMPED BY OTHERS AND PAID SEPARATELY! ' NOLANDSCAPINGRESTORATION ,OTHERTHANGRADINGDISTURBED AREAS, IS INCLUDED UNLESS SPECIFICALLY STATED' P PCOPOSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars ($ ). Payment to be made as follows: A FINANCE CHARGE OF PER MON7H VOtL BE ADDED TO Att UNPAID BALWWO CUSTOMER IS RESPONSIBLE FOR ANY AND ALL COLLECTION FEES. ALL DISPUTES ARE TO BE SETTLED THROUGH BINDING ARBITRATION. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Authorized Signature involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This proposal may be n........,.......,. C.H.. ,.,..,,,...a — _........._ withdrawn by us if not accented within days. Arreptanr a ®8 PrOP0901 —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as ' specified. Payment will be made as outlined above. Date of Acceptance: Signature S u n rn bro Travis ztf r; Corners �cT vs South 74 Highig nd scawa a Corn caaw 6*/ 05 Win. N I T G-ro KS wpm_ PUT . Tt A . m EY Ous Mum Adams Corners ose Hill Pat* 9p Kf Cem -1.0537 o R FO wh CO tine ita Village 13 �F uft C U! ,Ty VALLEY TM - CO U CH S TE J., % J, . 140 Moheganj N P, na Vill GRIDS STREET RIM A-0,57 -7-3. t,�8; Op!Od y .Tower .Rdq �B�U!� " The B 6. �HdWnio�,:qq� ::��'MX4• !,Mount �1 (3T Kl� 18 1�11!1 7!!, ,J1, Rd- 9. 1. �`T M HQ,; 5� " i "I m, • -'4 B hle.rj� irb PDutohO887Lak6,CtMt�L L. tfW MeVvr,6-'=U'=R; d Z b AA fj k&D N