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HomeMy WebLinkAbout0796DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24.-2-8 BOX 9 Li , T 6 1 r 00796 _J ' PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR _ YES NO internal Use Only PERMIT # -Q��'LJ� ❑ Repair Permit issued in last 5 years 11 Not in Watershed ❑ ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. ;M Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ° u Joint Review SITE LOCATION 2L11_p0 a r,2 TOWN Aztaev TM # � OWNER'S NAME -51eW„ kwgg ,,y PHONE # -� -�D fa MAILING ADDRESS pie. APPLICANT 1/0 1*tc?S_ 6 seAwd �+✓fi Name & Relate ship (i.e., owner, tenant, DATE v© FACILITY TYPE *AyLs e- PCHD COMPLAINT # PROPOSED INSTALLER ", PHONE # ADDRESS 3 rae �-nl., �� REGISTRATION /LICENSE # e- X3/ Proposal (include a separ to 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 Re I ;< 77a Lew I �! ifs • C ! ,i O � / - W Tca,i k I­ -/e- (goo o -1,ea vet I, as owner,agree to the conditions stated on this form PcDH- 6,h-e- SIGNATURE ,.44" TITLE DATE (owner) I, the septic install , agree o comply with the conditions of this. permit for the septic system repair SIGNATURE TITLE /�c� DATE G,2, t?,P (installer) Proposal a o d with the following conditions: 1. Procurement of any Town Permit, if applicable. f 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. J 5. /No completed work is to be backfilled until authorization to do so has been obtained from the Department. �/ INTERNAL USE ONLY Pro osal Approved /-- Proposal Denied ❑ G 3 1I o� & (r Log In ector's Signature & Title Date Expiration Date Re air ro proposal is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev, 2/07 Q U/r /s A /a. Pilo ilo "� z �e Aloes op, �eG 1 d.. —c ,o dou)e, .5 i�-- rlfl��Il ON AA T J 6wel l 0 1 `` �y f i '3 4t' 0