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HomeMy WebLinkAbout4861PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES D PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR 'ES N Internal Use Only PERMIT,e 4 ❑ 2 epair Permit issued in last 5 years VNot in Watershed ❑ kvz 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 / %QT,q„� 4 wy,Ik fp TOWN TM # 93,66--.2 --3 OWNER'S NAME �/,1���,� j�, �P L(_ �`�, PHONE # c%/?�--_1I33 *59 MAILING ADDRESS �'�� iRS >,det•e APPLICANT /t,.��e- �t /�✓' Name & Relationship (i.e., owner, tenant, ractor DATE - ! Z- Z.O 11 FACILITY TYPE S Q S PCHD COMPLAINT # P PROPOSED INSTALLER �..c PHONE #8c1s -629- ,OGZkt ADDRESS,00(.O �lasr rnz� _TREGISTRATION /LICENSE # 101 1-7 " Proposal (include a separate sketch locating the house, 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 to the conditions stated on this form SIGNATURE TITLE 0),OA.1E2 DATE i cmg"A if (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE_ DATE _ (installer) 0 GP 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 functi . 5. No completed work is to be bac lied until authorization to do so has been obtained from the Department. INTERNAL USE ONLY ® Proposal Denied ❑ p qt-4 �AkLk I � Title Date is in comDliance with apDlicable codes Yes COPIES: PCHD; Owner; Installer PC -RP 99ML 5� K rel�W.ZMP-ml OF\1 CS, c �n lIt -7 114 11 Expiration Date No O t)Ait k �i( Rev. 2/07 ARROW EXCAVATING, INC. 15 AVALON. COURT HOPEWELL JCT., NY 12533 (845) 227 -4505 (914) 528 -4395 JOB _1 _ fli�.�e t/ % /e ✓. zyo zu S y�y SHEETNO'oe��I'eG -?Ve OF CALCULATED BY y &A c _T'v DATE L9 CHECKED BY 2 &41 -61- / DATE Y 7 _ Zell ARROW EXCAVATING, INC. 15 AVALON COURT "MM4 HOPEWELL JCT., NY 12533 (345) 227 -4505 (914) 523 -4395 JOB SHEET NO. OF CALCULATED BY p '� A LU� DATE ` � Z ��► CHECKED BY SCALE IL DATE 0 I Geneva Road Brewster, NY 10509 845.80 8-1390 Fax#845- 278 -7921 Fm, Tol-r(O('s �X'Cct✓kT 11r'r'., � n From: n L ,) e l J Fa:c 8 I�s 2'2 G ` `c2 7.2 Pages eJ ; n J i'. Ca a4 r . Phone: �2 � ate: Re: iCAft le W y R�, CM 0 Urgent for Review ❑ Please Comment 0 Please Reply O Please Recycle • Comments: 1 l 1/11tS1 Q�iNI'� P ©hly Un w.e U les��n � " I�[ai C, P.LJej �� �all�c fe (acer�en?' Cat, Se-k P� � JJ CA A- OL A141 -e Putnam County Department of Health n From: n L ,) e l J Fa:c 8 I�s 2'2 G ` `c2 7.2 Pages eJ ; n J i'. Ca a4 r . Phone: �2 � ate: Re: iCAft le W y R�, CM 0 Urgent for Review ❑ Please Comment 0 Please Reply O Please Recycle • Comments: 1 l 1/11tS1 Q�iNI'� P ©hly Un w.e U les��n � " I�[ai C, P.LJej �� �all�c fe (acer�en?' Cat, Se-k P� � JJ CA A- OL A141 -e ��l!..�� 5y�.'p?� i. • -Y,�Syyr `+i" •1`.h_Y'a .'ro; ° "t ,1" Y"• i1: 1 ,r'�`r 'iiT4 ` .,�m� • ,r"m:..,;,+�� i7 "5:;� 'rvr ,�wg .,,,-;,r^ �ax�"'C�Ya`g�`n•., r• 'f 5., ,?L;5�1�9! i. ° Ai.�.y4 fl to x� - .l�p,C 7� x•,- �ayr�/, ,F r"rfe - "" 'V.•'L %Rnfy�'�'t'79 ytg ;J f e a "`s ' ;••`�'l� N§'F:rvr� y PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICESIt ( �� PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use Only PERMIT 0 � t Li LI Repair Permit issued in last 5 years CVNot in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ 0 Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION /�° �,,� p`� k) e,,7 TOWN )O /,r'' TM # OWNER'S NAME X0 /1 � AP L1._r/rr" PHONE #��,/ MAILING ADDRESS APPLICANT .r'iyr,.1 -x ;ca�.� ✓� ...,c .- Name & Relationship (i.e., owner, tenant, onirtor DATE - i l FACILITY TYPE } PCHD COMPLAINT"# A/co PROPOSED INSTALLER �2�2t >� <, k 1� Ls,Gt�,.� ,. r PHONE # ' � ,- ca �( ,> --0 ADDRESS [.ta I-�ca a �o r a �. �? i1. d .Nl l !j- REGISTRATION /LICENSE # Proposal (include a separate sketch locating the Douse, 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. arms; .,'. ^ -! {• „ -� e:�`t'w. Tra_� i •�:.. -. c' T.. ✓l C'�� !�` �. '�f.., /U �/ 7�ry._ i ; 1.r 1� 5 i _ r .! �. four �'- � t i •i f + ��..Y9 r' C . I, as owner,agree to the conditions stated on this form _.7 SIGNATURE f r : ` TITLE DATE.;. (owner) 1, the septic installer, agree to comply with the conditions of this permit for the septic system repair f. SIGNATURE A n- „ j ,. � TITLE DATE e i ( installer) lJ C7 , Proposal approved with the following conditions: 1. Procurement'of any Town. Permit, if applicable. 2. Submission of as built repair sketch.bythe 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 bac ” Iled until authorization to do so has been obtained from "the Department. INTERNAL USE ONLY . P o sal" pprove Proposal Denied ❑ Ins ector's Si nature Title <. f�r..Y? 3:Da a :jj'vv P 9 . Expiration Date Repair. proposal is in compliance with "a " licable codes Yes `y No 0-,- COPIES :. PCHD; Owner; Installer �' `� PC -RP 99M L ii i" 4 i Rev. 2/07