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00922
PUTNAM COUNTY HEALTH DEPARTMENT }
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROMSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES ..NO /__ _ __!nternal Use Only PERMIT # �-
❑ / Repair Permit issued in last 5 years ❑ 00t In Watershed
❑ IIG Repair within Boyd's Comers, W. Branch or Croton Falls Res. legated ly 6L-
❑ ',ARepair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION x-%0'2?/ -/o� v,l.arv,0 �� TOWNS G if r\) TM # 37 2�/bO .�S, �i� --�-J3
OWNER'S NAME OL SS cL, r1 ."rJly PHONE #
MAILING ADDRESS t4 e, ITerzo3 N .
::,APPLICANT C) G `,�N c h I N G� ClDjr-
Q [ ! me & Relationship (i.e., owner, tenant, contractor)
DATE U �7 ° C� FACILITY TYPE J��S��P��e PCHDCOMFLAINT#
PROPOSED INSTALLER LO cA s pl Z N C PHONE # qv- -
ADDRESS o� /'�'c C h a I J + C- CA 40h-1, REGISTRATION /LICENSE # 1
Pro osal (include a separate 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 �0 / O
L -as owner ,agree to c ditio ated on this form - —
SIGNATURE TITLE �/t&-� DATE O
(owner)
I, the septic install ,agree to co ply with the conditions of this permit for the septic system repair
%6JIGNAT U1
(installer)
Proposal approved with the following conditions:
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 gala 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. No completed work is to be backfi ed until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal ApprovAd Proposal Denied ❑
Signature & Title Date Expiration
osal is in compliance with applicable codes Yes 0 Nc
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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FOR ADJOINING AREA SEE MAP NO. 13
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