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HomeMy WebLinkAbout0657DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.09 -1 -15 llem 00657 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR YES NO • Internal Use Only ❑ Repair Permit issued in last 5 years F1 in Watershed 1.1 Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ - Repair within 200 ft. of a watercourse or DEC-mapped wetland ❑ Joint Review rco -*441-- •t tip* PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION A P� t-I I t✓t_- OWNER'S NAME •A MAILING ADDRESS SA iNl f:-;r A, S A 3o OFFICIAL USE ONLY (�� I V� - �)q�7-. TM# 23, 0 9- I - L PERSON INTERVIEWED PCHD Complaint # Name Relationship (i.e., owner, tenant, etc. 1 - DATE TYPE FACILITY PiOM-C: PROPOSED INSTALLER Q'.ArV1=D SePTIC- PHONE Q1 - Z Z' / ADDRESS // )1 WL%QIJ D AVE- �c.vFc2a fli.� REGISTRATION# � Proposal (include sketch locating all adjacent wells): /oSo7 ate' 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. /N.i 7 /1t- cj i/c /J rid /vGL✓ ie'410 e A , P4AJ-7 1c sEi�i /L 7AN� � �t't1'7bvL� �Lp ii( iAi�•K. /S �Ct'i CrR�. iYl�?/lC' Gt7t.A i�L`i� j,bvl�- /34 I, as owner or reported gent of owper agree to the conditions stated on this form. SIGNA � 1 TITLE DATE 2' Proposal approved with thefollowine conditions: 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 comers). d. System description (e.g., 1250 gal: Concrete septic tank, three precast 6' diam. e. Installers' name and number. 3. System repair to be peyrformed in accordance with the above proposal and conditions. Proposal approved ✓ - &?-e ` -Sp, Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML X 6' deep f 1Yg- 7/06 DATE PUTNAM COUNTY HEALTH DEPARTMENT brvism OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FORS DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY SITE LOCATION TM# OWNER'S N PHONE MAILING ADDRESS SAME: A,-S A80JC' 12-S PERSON INTERVIEWED PCHD Complaint # --fraine I Relationship (i.e., owner, tenant, etc.) DATE TYPE FACILITY C11 4� PROPOSED IN Q-Qn-SD PHONE Be- ADDRESS 311 D /1- VC REGISTPATION# 4- -7 Proposal (include sketch locating jacent wells): /V 5"o Fmg as_-on NOTE: Repair must be in same locatMon' *ginal S _ ewage disposal system Different location f -dfigihe6 r may require submittal of proposal from licensed professionar o registered architect. IN S -7,4 1. 1,A—i i,,AJ OLE /vow 10490 -E0o2-7 /4 -7,4AOA—' 1 &p-j(0S-7/,V6- S'00 recur C-T a C.,.- (-&V I,as.owner ZY orreported gent of oy�per agree to the conditions stated onthis..form. SIGNA "a TITLE DATE -"A"7`2 TU Proposal approved with the following conditions: 1. Procurement of any Town pemlit if applicable. 2. Submission of as built repair sketcl , in duplicate showing: a. Owner's name b. Site Street Name, Town and T�-.,Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 go. Concrete septic tank, three precast 6'diam. X 6'd. e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved v,," - Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town Bl); Pink (applicant) PC-RP 9%E 6 DATE S' 1 �9�- -T3tJiL�� LO�ATIOIUS s Se vie fi AJK t l n 2 S-e V-n a 'M4- (ovrleT) 1 ( z e.■ -- 1000 GAL -Pel F.-Y .SE n77 G. -rA -^JAL. w N- 1APIS X PLAC. o A- r000 6&L- Mr —rAL. 5CP7i4- 7hAig• WLXI A7. pA'ff�o�1 N :1l• t 2�6� ,V6 /0c .. UNITIED SEPTIC A EXCAVATIOM CORP. E19 RAILROAD AVE. BIEDFORD HILLS. N.V. 10607 .V. Tel: (914) 242 -1999 Fax: (914) 242 -1909 UNITED EPTIC & EXCAVATION CO". A Union of Costa & Ferreira, Inc and S.A.F. Septic Systems, Inc. {Family owned business since the early 60's) 311 Railroad Avemie. BedfordlEUs, New York 10507 phis ;s 4 �Py —,ee L, E z_-7 /47n le-- / Z - 7-- a Street - Town `:= State Zip y PERSON IN CHARGE- g (1R 1NTFR VTFUtTFT) �%ii �?-� S� iG 'Date' ! ! - I 0� to 0 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL.HEALTH SERVICES L SITE LOCATION 14 1 L-C, Fk 1 . TM# 23. o OWNER'S NAME M •A 'R-y l /16 X - PH MAILING ADDRESS SA M a 10-,,S 860 OFFICIAL USE ONLY PERSON INTERVIEWED PCHD Complaint # ame Relationship (i.e., owner, tenant, etc. DATE TYPE FACILITY. PROPOSED INSTALLER (AI iTt✓'D PHONE �vFo2a ADDRESS // 941Le0A Q 1 �I /t t- REGISTRATION# /oSo 7 Proposal (include sketch locating all adjacent wells): Cte' 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. lvi4,L 1400 CA S;�j� ,1' � S - � iiv' `� .s i % -,l:' - i ��C. ir') .�r /c.. I S ..� i.' R °� 1,.� 3�1'•L..: il'16 �i1''G.. Gi:� E-y1 i i �� �:J �,L � � � /_.�i l f%l tiken. %) /!��' A-11,,:°A.: a/f 4 r iC J-1 0�4c a t_ �� X o s[i�a L.�u • /� s�� 0.r re It m� 5c�' rvue f� I v? �e ge)x - I, as owner or reported gent of o er agree to a conditions stated on this form. l,�l. SIGNA � TITLE DATE 1W ZCxrD ' 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 p rformed in accordance with the above proposal and conditions. Proposalapproved u g Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML