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HomeMy WebLinkAbout0100DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.19 -1 -79 BOX 2 T} IN 11 ' �� •, oil pin l._ 00100 SITE LOCATION OWNER'S NAME PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES a PR POSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR NO Internal Use OnlyC��-►d i /F Repair Permit issued in last 5 years ❑ in Watershed Repair within Boyd's Comers, W. Branch or Croton Fails Res. Delegated Li Repair within 200 ft. of a watercourse or DEC - mapped Welland ❑ Joint Review MAILING ADDRESS COO �- t R APPLICANT �pyL-} -rrC Name & Relationship (i.e., owner, tenant, contractor) DATE i () I O FACILITY TYPE CHD COMPLAINT # 3 PROPOSED INSTALLER PHONE # %6-- CiOC�I ADDRESS 44, 2A11- v)ci REGIS* EGISTRATION /LICENSE # - �- l� lyC sAg�, r1�ax��.11 a_v 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 trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. �.»,L r 'eSk�rG� 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points d. System description. (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions. Proposal proved Proposal Denied Z/ le96 I spector's Signature Urihe Date' COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Sent By: MR ROOTER PLUMBING; is ail ,00f Nov -1.08 11:48; of o. Yt in C- 7 ce Page 3/3 4. Trl • PdS-P7P-7qP9 VAMP- PI ITHAM f-Fil IKITY nf=pnPTMPl-JT np p 7 Sent By: MR ROOTER PLUMBING; 845 635 i173: Nnv -1 -nA 11•AA- Page 2/3 NOU -1 -2886 klED I.J.::_ "A TEL:845- 278 -7' 81 NAh1E:PUTNAM COUNTY DEPARTMENT OF P. 2 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SWAGE DISPOSAL SYSTEM REPAIR YE NQ internal use only ❑ .. Repair Permit issued in las! years LJ Not in Watershed 17 -r✓ Repalr within Bcyd's Comers:, W, Branch or Croton Falls Res. La Delegated U L�Repair within 2D0 ft. of a wat rrcourse or DEC -map ed wetland ❑ ,Joint Review SITE LO ATION ':3 Atzrr r' (-7 I tILL; R.-P> , M A H 0'r-A TM OWNER S NAME C (11 Cle (, A N. C -PI rZ i 7 �t{F PHONE MAILINC ADDRESS S(tiNt�� APPLIC NT /v1 r1, t<ou � Z PcvAU3j (T { i"i.umaP Name & Relationship (i.e., o ner, tenant, contractor) DATE Iv 1 r -o j -FACILITY TYPE, k, PCHD COMPLAINT # PROPOSED INSTALLER M�� Ru� -76'Z p(.6- CioiT._ _ PHONE# ADDRt= S `,- - -`.�` ;7 j:r)Gh +_ I'iL-w.j A,�7 v&tr1 REGIMATION /LICENSE # l "�'. :Z' =i �f� -/? N Propose' (Include a separate sketch locating the house, prolmrty linos, all adjacent wells within 200 feet. of r pair and the location of existing anq proposed trenches) NOTE: epair must be in same location and of Oame type as original sewage disposal system. Different ocation and proposed pump systems Will require subrri ttel of pr6posal from licensed professional engineer or registered architect, t+�rua i �_Y:� (�ifaCtt?►i s�Y �,� -��,� _, -.., ,r,,,. l} L t- _xr M o I N c L v? � E^P r rt F_r (,'Its- L J_ kA&It. M,4bF C) F C0 0i 1'7f2V -71p,-1 10(.K- C L✓t ja i'� -IY E CA�raL a,RA!!r � (,At L✓i'tn ��' IN�rLK/1`70C� �V T,S/(tlii 1, as ow r, or r d agent a owner agree toithe conditions stated on this form SIGNAT JRE TITLE t,r DATE Proposal woroved with the following conditions: rement of any Town Permit, if applUble. 1. Proc 2. Subn lsslon of as built repair sketch in duplicate (showing: a. 0 vner's name b. S e Street Name, Town and Tax Map number c. L cation of installed components tied to twoIxed points d. S stem description (e.g., 1250 gal. Concrete aseptic tank, etc.) . e. I tallers' name and phone number 3, System repair to be performed in accordance with the 2bov,, proposal and conditions. Proposa Approved Propossil Denied I ct 's igna re Title Date COPIE White (PCHD); Yellow (Town BI)j Pink (Installer). Orange (Applicant) PC -RP 9ML Rev. 8/ NOU -1 -2886 klED I.J.::_ "A TEL:845- 278 -7' 81 NAh1E:PUTNAM COUNTY DEPARTMENT OF P. 2