HomeMy WebLinkAbout0723DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
23.13 -1 -3
BOX 8
00723
V�.
PUTNAM C+OUIY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL. HEALTH SERVICES
PROPOSAL FOR SEW"ERMOSAL SYSTEM REPAI
NO/ R!
use —
❑ /' raeperr F� bSWd is tie 5 Veers ❑ Not in Watershed
❑ Q gr in BWft (nn% w Bin or CMw Fars Fees. .❑ nabMwWd
C� v*ft oaf a�
❑
� a wwo ats R /mod wrsend A A\, .!silt ArlYiwRl i
SITE LOCATION.- C 7 e. lle
OWNERS NAME
MAILING ADDRESS
APPLICANT
& Relatfori tp p.e , owner, terwK am ramr)
TMOOS, 1,6-17
PHONE # O 7V -�c%
DATE FACILITY TYPE PO/a/iPCHD COMPLAINT#
PROPOSED INSTALLER _ 7v �/ l/ll����. PHONE #
ADDRESS G�O�,�' REGISTRATION /LICENSE #
P (include q 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.
P
I. as owner, or reported agent owner agree to the conditions stated on this torn
SIGNATURE TITLE
ns-
1. hf any Town PenrdL if applkstte.
2. won of as sketch in duplicate s xwft:
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., 1260 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be peftrmed in atxotdance with the
above proposal and condHbr�s. /
Proposal Approved Proposal Denied
ff "I > 4 P" 0- ej:: ��
r
nspeda's Signature & Title pate
COPIES: White (PCHD), Yellow (Town 81); Pink (installer), Orange (Applicant)
PC -RP 99ML
DATE f
lost YM
. . . . . . . . . . . . . . . . . ........
too
till
's
m z
M.'� -W.
.
....................
" P4
a § Ono n" VA
W! 1 ion
z
owl
... ............
MIAMI!.
40
T Vol 4 TAT :0 W
WANT
W
too
. . . . . . . . . . .
ZVI,
"T
...............
'T
igh'a cure iand'T it*l
11POR if �"hV'
v
To: Danny Shedlo
Fax number: 1'- 914 -773 -0343
Re: Septic Repairs
A facsimile from
Putnam County Health
Dept.
Karen Yates
845 - 278 -6130 ext. 2154
Comments: Please let me know if there are any problem's
b
Fax:914- 773 -0343 Aug 6 2007 12:10 P.03
Y ° �rMtNr New York City
m Department of
Environmental Protection
SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR
DETERMINATION
Pursuant to the authority granted under:
Article 11 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 Household Systems;
Putuakn County Septic Repair Program Plan — March 2005. .
DEP Project# CHID Repair# i d 7
Site Location: Qs- �•'�`� hd �� c+l��. %I.�I T.1 T.
� � d / � r
Reason for Joint Review:
Drainage Basin 2001 of WC/Wetland t1l Repeat Repair in 5 Yrs._
Name of Owner:
4
Owner's ,Address:
Drainage Basin of Project Site:"`�°�
Installer: _ 1 t, Wet 1( --
General Description of Sewage System Repair.,
J e �. (A r
k Vt, 1 ace w, e
Dates of Site Inspections and Soils Tests:
Approved
*Incomplete a Delegated "Denied
-
Approved
Soils Tests Repair Sketch, WC/Wetlands Wells Other
* *Reason
7Engin an made by:
g Di vision Date
August 2007
A
t. 22'
1. 31'
16
lovino
Ludingtonville Rd
Patterson NY
Tax map# 23.13 -1 -3
"-' tank (1,0000 gal)