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HomeMy WebLinkAbout0112DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -1 -28 BOX 2 ME i r ,, ,;61 • r { rT , ., JL: or ,Ir . 16 �• 00112 A Ph ..ry.: ,,..}�� ..fi,n;d..•E` �, -'� ... iy.:i ,�..�,�<o �; r_,...••i �„ .. ,.. ,..., —..� .. .. ._ ' ..F� t t t PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR 11 YES NO Internal Use Only PERMIT* -;)0Q-(1 ❑ ❑/ Repair Permit issued ih`last 5 years ❑ Not in Watershed ❑ ®! j' Repair within Boyd's Comers, W. Branch or Croton Falls Res. Er Delegated ❑ © Repair (within 200 ft. of a watercourse or DEC-mapped wetland ❑ -Joint Review SITE LOCATION (D 0t°�(wd �- • L TOWN A '. TM # �( OWNER'S NAME !.-tarryly. -e' 1°,Ar+ick PHONE #' MAILING ADDRESS APPLICANT C! i Vi't6't; f, 175 hQ,(,,j r . V,, a Name & Relationship (i.e., owner, tenant( cones tractor / DATE FACILITY TYPE PCHD COMPLAINT # �0 PROPOSED INSTALLER Pir • (-b A.(( t $ PHONE # /� ADDRESS P6 ,oy I—M() l� !a,s r mj Vj f Q REGISTRATION /LICENSE # I 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 ture and went of the repair. UP 060. TOW- MPJ a. t-� L n k1a sAP. 10 Cdt Iy' p a�Ga� t ,M - �s va . i� rt4 y � as sad yr vy s 72> KA I, as ow' ner,a( to th onditions stated on t is for. P SIGNATURE ; TI ow DATE (owner) I, the septic inst tier, agree t0 comply with the con iti©ns of this permitfor the septic system repair SIGNATURE A TITLE c �.�r n Y DATE -3 (installer) Proposal approved with the following conditions: s . 1. Procurement of any Town Permit, if applicable. 4t 2. Submission of as built repair sketch by the septic system installer with 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 proposa'Land conditions — °° ° °" 4. The proposed SSTS repair is considered a best fit design and there is no\6 arantee 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 O No, ;O, COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 A =.12' HOUSE TO SEPTIC B= 16' HOUSE TO SEPTIC C= 21' HOUSE TO D -BOX D= 17' HOUSE TO SEPTIC E= 19' HOUSE TO SEPTIC F= 23' HOUSE TO D -BOX G= 25' HOUSE TO INFILTRATOR H= 19' HOUSE TO INFILTRATOR I = 17' HOUSE TO INFILTRATOR J= 23' HOUSE TO INFILTRATOR K= 36' GARAGE TO INFILTRATOR L= 42' GARAGE TO INFILTRATOR W �G Lorraine Furtick 10 Orchard Street Patterson NY 12563 Permit# R- 204 -09 TM# 3.20 -1 -28 AS BUILT DRAWING Distribution box FENCE 8/17/2009 4 NOT TO SCALE NOT TO SCALE NOT TO SCALE Shect l of PUTNAM COUNTY DEPARTMENT OF HEALTFI DIVISION OF ENVIRONMENTAL IIEATLII SERVICES FIELD ACTIVITY REPORT N A MF : A>2i�YY,r TPI: Street Town State Zip PERSON IN CHARGE Name and Title TYPE OF FACILITY.: _ .st ( no 000 Pvly Wou5 G TNQPF(`TQR; I') TFT Signature and Title REPORT RFC'F.TV'F, BY' 1 acknowledge receipt of this report: SIGNATURE: 02 / 96 Title: lu — ° r� IGJ i�� far �7 K� U �fK/i�a.•I ✓�`r/a c " T y no 000 Pvly Wou5 G TNQPF(`TQR; I') TFT Signature and Title REPORT RFC'F.TV'F, BY' 1 acknowledge receipt of this report: SIGNATURE: 02 / 96 Title: �CQ� -" 3kS r5-ZI v -�z " cla iDfi c �, j45