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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4A -28 BOX 2 Lo rr F AO ,` 1 00164 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES r 9 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAI YES NO Internal Use Only .— ®0 ❑ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Vioint eiegated ❑ • Repair within 200 ft. of a watercourse or DEC - mapped wetland Review SITE LOCATION %% t TM OWNER'S NAME ]�t4,A, (� 1 ,� PHONE /'X,� -22 � MAILWG- i4DDRESS; . j lL= g-7-114 �Q�T�> �1n,� 2-Z-3 APPLICANT,.liu►.�.1 Name & Relationship (i.e., owner, tenant ntraZ! DATE 7-- FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER y PHONE #�� -►5`� ADDRESS M4 J, - 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 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 anninaar nr ranictarari nrehitant 1, as owner, or reported a of owner ree to the conditions stated on this form SIGNATURE ' TITLE DATE 7- ,C1 -Q'� 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 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 Approved _ y Proposal Denied '44'r' 4--, :67,� 0 3 0 ffispector's Signatu e & Tit Fe Da COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) or_QA QQnni r RooTe 311 9S'- tj 7 qqr F . 9- 6- 07 311 7a /000 IdA.U14- /1J -UJ4J Mug 1 4uuf II..Ju r.Ui oV OFPgRrM� New York City N�. 2. °� Department of ii Environmental Protection SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR DETERMINATION Pursuant to the authority graxtted under: Article l l of the New York State Public Health Law; Rules and Regulations For The Protection From Contamination, Degradation and Pollution Of The New York City Water Supply and Its Sources, 15 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR Appendix 75 -A Wastewater Treatment Standards - Individual 14ousebold Systems; Putnam County Septic Repair Program Plan -- March 2005. DEP Project# - PCHD Repair# Site Location: - 31 T.M.# Reason for Joint Review: Drainage Basin 200' of PVC/ Wetland Repeat Repair in 5 Yrs. Nance of Owner: 11LAced.. -t - PI/ ()JCVci� Owner's Address: Drainage Basin of Project Site:`` Installer*. �. uv7f fc .ra�� J /�,�v General description. of Sewage System Repair: i _�_Za __ 1 Plates of Site Inspections and Soils Tests: Approved !✓ *Incomplete Delegated * *Denied *Required: Soils Tests Repair Sketch - _WC /Wetlmds Wells Other * *Reason bete on made by: -1 67 Engineering Division Date Vt< I V (_-,, &/,.?-v Y 52 50 8.42 AC. 'CAL 3 74 CA! i Y 51 AC. \ 9.10 AC. CAL: i i IY I 45 18.36 AC: CAL. 1 i el gI N 916000 0 55e A101. ` 56 / n jt A•I -4c ESSMENT PURPOSES ONLY REVISIONS SPECIAL DISTRICT INFORMATION 51A1E Llr¢ E USED FOR LONVEYANCES a Wta➢ /. ar a�.ee tnrn w� COUV LINE 7011N LINE PRUM0 Rt ruoc alitsm ua VILLAGE LINE W. SEWALL COMPANY STREET OLD TOWN. MAINE �ooEnfr u" ORIGINAL LOT LINE un w« rat a/at /at rj n.Aat •�C. Lin. ■r' I . -001 . _. �'. '�' 1: �- �` .- � � ,,,, , , - I- " , - ", , _ - �,: - � ", nwnq��"a, , . 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