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HomeMy WebLinkAbout0597DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 23. -1 -64 BOX 7 00597 ; �,. .. 16 . kwillpi 16 - " L .. 00597 F PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES YES N Internal Use Only ❑ pair Permit issued in last 5 years ❑ . Repair within Boyd's Corners, W. Branch or Croton Falls Res. El 11 Repair within 200 ft. of a watercourse or DEC -map w SITE LOCATION iCj I �'I A m +6 Mev W MTOW N _ OWNER'S NAME �I.i7��1L. j ZX1 MAILING ADDRESS '> L H 1'7kr^r�✓1n M APPLICANT TEM PERMIT # I-T W ❑ Not in Watershed J- Delegated -•4&Ak oe (y ❑ Joint Review TM# — I PHONE # -aL11--3r —4TY0 107o - 61y.2 Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INS ALLER r T�����t -�� PHONE # ��f S =�p�(7 ` &0Z qil ADDRESS REGISTRATION /LICENSE # Progosal (include a sepa ate 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. f r I, as owner,agree to nditions stated on this form SIGNATURE tt TITLE 0L4jg_Z.a! DATE v (owner) I, the septic ins , ag o c ply with the conditions of this permit for the septic system rep r it SIGNATUR TITLE &Q ' ' DATE 7 0 (installer) ri vkUaai uWIJi vvvu mu I u is ivnUwn Iy wl wuwi w. s 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. o completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pr osal Ap d Proposal Denied ❑ I pector's Signature & Title Date Expir tion Date Repair proposal is in compliance with applicable codes Yes O No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 (Q! M656.6244 0 AS BUILT FOR - ELIZABETH GHITZA 514 FARM TO MARKET ROAD BREWSTER, N.Y. 10509 - 6142 BAKER EXCAVA` ON INC 57 EAST VACATION DRIVE WAPPINGER'S FALLS 12590 EMAIL @ BAKERSEPTIC@OPTONLINE.NET Hc;us>= ar-TI c TANK /09 SEPTIC INLET OUTLET TANK A 9' 14'4" B 42' 43'6" BAKER EXCAVA` ON INC 57 EAST VACATION DRIVE WAPPINGER'S FALLS 12590 EMAIL @ BAKERSEPTIC@OPTONLINE.NET Hc;us>= ar-TI c TANK /09 I Sheet_ Of_L PUTNAM[ COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT . NAME, �r �,f I T P.I: \ Street Town tate Zip PERSON IN CHARGE ng rNTF.RvTF. r) 9; .4- 0-*0 Name and Title TYPE OF FACILITY FINDINGS: v,j �� tC C 04 • ,�;� /,iL �,"� Si rt e $FPORT RFC'FTVFT) RV• I acknowledge receipt of this report: SIGNATURE: 02/96 Title: P017 (e,45)656-6244 SAKE R /09 AS BUILT FOR - ELIZABETH GHITZA 514 FARM TO MARKET ROAD BREWSTER, N.Y. 10509 - 6142 ExcAvA` iON INC. 57 EAST VACATION DRIVE WAPPINGER'S FALLS 12590 EMAIL @ BAKERSEPTIC @OPTONLINE.NET .,ELL HOUSE SEPTIC TANK SEPTIC INLET OUTLET TANK A 9' 14'4" B 42' 43'6"