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HomeMy WebLinkAbout0106DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -1 -15 BOX 2 �A'' I''''' ' ' ' • 'I' k'o I % I Is ■ 1 00106 It�vl��.i�c�n 6�ttS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION OWNER'S NAME & k G MAILING ADDRESS T S T r OFFICIAL USE ONLY TM# PHONE III ` / -,iC3 ° T7 i PERSON INTERVIEWED PCHD Complaint # Name & Rel.ationship i.e., owner, tenant, etc. 1., J) e61 roo.J A pmr)n;;,7 DATE TYPE FACILITY /— Bpd R.no� 00W,1STo6/15 PROPOSED INST PHONE !f/15- -656 —J� % q' L ADDRESS R9 q J0- 425`g &W, REGISTRATION# PC. 195 J Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. I, as owner, or repo gddent of owner agree to the conditions stated on this form. r--, SIGNATURE TITLE�,[�y, DATE Proposal approved with the following conditions: 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 (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6 diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved_ Inspector's Signature & Title DATE COPIES: White (PC) ID); Yellow (Town BI); Pink (applicant) PC -RP 99ML ll�J.. 0 b_ L � Aq!lI Z. 3il A;. - 3, � ate ret+ 'N 4OL4 -f P 31 pofI iersoA K PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR YES NO Internal Use Only ❑ e Permit issued in last 5 years ❑ t in Watershed ❑epair within Boyd's Comers, W. Branch or Croton Fails Res. legated ❑ ;/Rpair e within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review PUTNAM COUNTY HEALTH DEPARTMENT ,`��,N► CO DMSION OF ENVIRONMENTAL HEALTH SERVICES a, tae * PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY aD — � 0 SITE LOCATION //la U311 Po+iV15M TM# 3 Ado -1-1s_ OWNER'S NAME ik 6 r c,4 PHONE il` /-i?63 — 7/ i AILING ADDRESS M PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e., owner, tenant, etc. � _,g ecl roost q perr+ DATE TYPE FACILITY I— 8A A,0,101 0a`U'1ST."in5 PROPOSED INSTALLER ADDRESS q Jb_ SB n AJ, REGISTRATION# PG l K,56 Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location mad require submittal of proposal from licensed professional engineer or registered architect. I, as owner repo, ed ent of owner agree to the conditions stated on this form. SIGNATURE, TITLE_ "a.�.l![ DATE Proposal g =ved with the follo�conditionsg =ved with�e following I. 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 (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approve Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE 0 1/£ J yJ IZD JO d.7 - 'Ira ,I- Ilk Do -1 IIA Nvro+T -q A `poll 4rsr, it)ly� PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ;j „,,,,,_,,- RROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES NO Internal Use Only PERMIT # ❑ Repair Permit issued in last 5 years ❑ Xt in Watershed ❑ . ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION (C' /Z`- 311 TOWN �:i j' �">`.'� ory TM # 3. j-o •- j OWNER'S NAME 4-ke. PHONE # �`LJ”- ' -6 7 (,C) MAILING ADDRESS _ S� �'l "-,ft V,•'Jje /I- J / ,� we -!/ AlJ / ,A 1 3 3 APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE ,��, Oly FACILITY TYPE. 6�., v S z PCHD COMPLAINT # AW'k PROPOSED INSTALLER �G%lli ie S �ti� � PHONE # 4, 5-6 S'7 I ADDRESS �=� ��iry�� /;�' �g,1Y`idEc,l %e REGISTRATION /LICENSE # 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 nd extent of the repair. ill ��GL (... -� 1 �� a]l.. /(,a�j.., �GcX -N,���' d� ✓• "��. �G G)i,► 'c,' �.II..T'�_ /.�_., �,.i_..f� �..n li' lQ ui' I, as owner,agree to the conditions stated on this forma SIGNATURE TITLE DATE (owner) I, the septic install gre t c ply with the ditions of this permit for the septic system repair / SIGNATURE TITLE ���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 backfilled it authorization to do so has been obtained from the Department. INTERNAL USE ONLY Approved re & Title is in compliance with apDlicable codes Af Date Yes 0 -57 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SEWAGE TREA SYSTEM REPAIR X YE Y ONO Internal Use Only PERMIT # t�~Qcx,0 — 1 ❑ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ Repair within Boyd's Corners, 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 t-11 Qn TOWN + &I MAILING ADDRESS. APPLICANT Name & Rel, DATE PROPOSED INSTALLER S qv, ADDRESSWI �� / q, n,1, Q,,, /A u a I /.. "'C4 s itionship (i.e., owner, tenant FACILITY TYPE "i G iegae S eg i TM #�'3 . 0i� — /r PHONE #$1 /s e?& d �(�] contrac PCHD COMPLAINT #� PHONE #9115 66G—S 7,91 REGISTRATION /LICENSE #,JQ �fiSy' 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 1, as owner,agree to the conditions stated on this fohm SIGNATURjj�. TITLE DATE (owner) I, the septic install�e1r, gree to comply with the conditions of this.permit for the septic system repair SIGNATURE,L/ TITLE DATE / ev (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 ❑ Inspector's Signature & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; installer PC -RP 99ML Rev. 2/07 I- � - . �,,�, - . - - - I- - - - ����--.-,--'�.��, �: , - -, �� 14, �t�, � , , I _� -. '_ ` ­.- �,,,� � � = � , , � , I I - ,� � -- - - , " � � �l �:! - - I . � �� �. 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" ,. - � � I - , _. 11, � - , ,. . . , - ": ", - - .,-,-,,,, - - � ­�,­ , � . 1�1, �� �:�� �� , - ,�� , � , �. �� , - , -.;. -_,_ - - " ., " ,� '-, -,- -,. , . I I .11, � - , o - , '': __ �, � I . -, ­ �.�, �.� i, - � , - � C�ii, , "I . � � - � . : . � ,% -i . � , I .1 I - - _. ,. - � - . .1 .. � � , , , , " 1a(`fet-F Pa��'�rs ©r► N PUTNAM COUNTY HEALTH DEPARTMENT `-%� D /-( 59 IVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY SITE LOCATION Col U 311 OWNER'S NAME , k`,- Gr r,-.- -#T' TM# . �)® / l,s PHONE `71$!- ;?e3 Cf '7 1 MAILING ADDRESS'_ Si,,rm u '►14e L d Nan A U, el 6 V r 12 S-13 PERSON INTERVIEWED PCHD Complaint #� Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY m, ,:,✓ tl �: r' 5 k , ra PROPOSED INSTALLER PHONE ,Tf I.5 - 656 —5 7 cf V ADDRESS r 1Jn 5 �a ,, LZ,f . REGISTRATION# PC. 3 Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage:disposal system .Different location maY) Xeglure submittal of proposal from licensed professional engineer or registered architect. �� � • � �''i)�G# L':A ;� X , 4 t n � (<+1 4'! 7� - t rJ � 1^. l � `°, i.:.+ ..' U �'? '�i:,c.�` / c...n � _ I, as owner, or reported agent of owner agree to the conditions stated on this form. SIGNATU /. '' `, `- ( -�^' -- TITLE . "t x !./.. a ..t Yet DATE r Proposal approved with the following conditions: 1.'A -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, Tov& and Tax Map number. C. Locafion of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. a Proposal approved •,;,,1 Inspector's Signature & Title COPIES: White (P CHD ), Yellow (Torw' ; n BI); Pink (apI ` pi .a t) , PC -RP 99ML Z f2 1 Z ,e_2 — 3 ATE u ��