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HomeMy WebLinkAbout0598DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www. s ca n y o u rd o cs . co m 631 - 589 -8100 23. -1 -65 BOX 7 6 IL LI , J. f - �� - ��, IN ro m-6 6 Z ` - b PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'ES NO Internal Use Only ❑ Repair Permit issued in last 5 years ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland SITE LOCATION t _91 WAG e d �r ❑ I>iolt in Watershed Delegated ❑ Joint Review TM # C OWNER'S NAME 'B E:LMq I`i �° PHONE # y /y— lfy y 313; MAILING ADDRESS AtXyvX"1`e/L APPLICANT- �*tl)1�-� Name & Relationship (i.e., owner, tenant, contractor DATE l c0 FACILITY TYPE 12- PCHD COMPLAINT # --0,6 • 1 1 PROPOSED INSTALLER 4,Adjzy) CtL461F,1 — PHONE # q-ti3' §_�tb ADDRESS Ui`�`f ►- VA ��� r. ,� REGISTRATION /LICENSE # &W 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. I, as owner, or reported agentloFowner agree to the conditions stated on this form SIGNATURE TITLE �` r "K j— 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 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 Proposal Denied f e t Inspector's Signature & Title Date r COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FIELD ACTIVITY REPORT NA • !� %� !1 �i� IsT,. n / Tel: Street PERSON IN CHARGE Town State Zip 67 Name and Title t TYPE OF FACILITY : 5S7-S �,45PA)iZ Ire,-vn,0ZZA-)1v;r Z,.Rkl ye- FINDINGS: n ;(Ee /S /' ✓ ©vt /OJG� O r`_' �TJG ovai ��vrn .4,610!NDoNg-4) �PA I /O 00bt S' 11MO Mb 19-�" Signature Title RFPCIRT RFC FTVFn BY: I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. Sheet 1 of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT NAME: Tel: Town State Zip PERSON IN CHARGE ()R TNTFRVTFWFT). hate, % 3.1 07 fL� - le Name and Title TYPE OF FACILITY: J�,,_ - it ( 1 %i 77-2 FINDINGS: �.zt s- reL r ► Signature and Title RFPORT RFC`.FTVFT) TRY. I acknowledge receipt of this report: SIGNATURE: 02/96- Title: Rev. Sheet` of_� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT A1)nRFS4: .2(�0� �.41.1� 1�AT1�T�SC1ill� Street Town State Zip PERSON IN CHARGE nR_TNTERVTFWFTI: e ©�aw z T)atP_ / Zia Z2? Name and Title , TYPE OF FACILITY: FINDINGS: Sew 4 -,, faM al- 0 u SMAOL l eeyrn Aj I m-c 11,a. =, . t at% 7 i :-I-% y ! Signature and Title RFPORT RF[`FTyFT) BY: I acknowledge receipt of this report: SIGNATURE: 02/96 Title: FIT M4 J4 6" o- t3 L - 33 A4 -tf il-e mac/' No F- r 7- f H 4 A, wy C L4 S'ZJL L -T Cc.ocrf tlGEC 100 C, (Z- 'ILD \��O �N ACC 0,, Ao OM O O� U 6 U- Environmental Laboratories, Inc. 587 East Middle Turnpike, P. ®.Bog 370, Manchester, CT 06040 Tel. (860) 645 -1102 Fax (860) 645-0823 Analysis Report FOR: Attn: Ms. Anne Bittner Putnam County health Dept. April 27, 2007 Env. Health Services 1 Geneva Rd Brewster, NY 10509 SgMle Information Matri= WASTE WATER Location Code: PUTNAM Rash Request: P.O. #: Client ID: BELTRAN Custody Information Date Time Collected by: 04/24/07 14:05 Received by: SW 04/24/07 17:30 Analyzes] by: - see "By" below SDG I.D.: GAJ08818 Lab®rat®gy Data Phoenix I.D.: AJ08818 Parameter Result RL Units Date Time By Reference Escherichia Coli >10000 100 /100mi 04/24/07 18:25 C/R SM9222G Fecal Coliforms 10200 100 /100 mis. 04/24/07 19:00 C/R 9222D Total Coliform >20000 100 /100 m18. 04/24/07 18:25 C/R SM 9222B Comments: If there are any questions regarding this data, please call Phoenix Client Services at extension 200. ND =Not detected BDL =Below Detection Limit RL= Reporting Limit a . AOL Phyllis hiller, Laboratory Director April 7, 2007 ]Page 1 of 1 a �J, a d � ]Page 1 of 1 _ CHAIN OF CUSTODY RECORD Temp' C Pg of 40 Delivery (check one): PHOData ENIX* `b87 East Middle Turnpike, P.O. Box 370, Manchester, CT 06040 Fax #: Email: service @phoenixlabs.com Fax (860) 645 -0823 ❑ Email: Environmental Laboratories, Inc. Client Services (860) 645 -8726 Format: [] Excel Pdf cis Ke Customer: Project: Project P.O: Address: Report to: Phone #: Invoice to: Fax #: Client Sample - Information - Identification e Sampler's Analysis °off Signature Date Request C' Xti`'��° Matrix Code: DW= drinking water WW= wastewater S= soil /solid 0 =Oi1 GW= groundwater SL= sludge A--air X =Other I V E d Phoenix Customer Sample P Sample P Date Time t' •� 5 `� F P� P � � �' a� 2 Sample # Identification Matrix Sampled Sam led K. Relin uishe !W: A¢ce ted b i Date: Time: Turnaround: 1 Day* 2 Days Requirements ❑ ❑ for CT/RI Res. Criteria GW Protection Requirements for MA ❑ GW-1 ❑ GW -2 I f ,�.' `4 a .. r._,� J ` - - '� E] 3 Days* Standard ❑ Other ❑ ❑ ❑ GA Mobility GB Mobility SW Protection El GW -3 ❑ S -1 ❑ S -2 Comments, Special Requirements or Regu t n . Rd ❑ Res. Vol. ❑ S -3 �� *Surcharge E] Ind. Vol. ❑ MCP Certification Applies ❑ RCP Certification ❑ Other /ufVl 1)t4 c '`s c ,�,.,(�, .P f 'x `@ pt- r 0) l4k- A- (- - "VIO pf Til/t fc scys K9