HomeMy WebLinkAbout1125DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.55 -2 -19
BOX 11
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01125
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR. SEWAGE TREATMENT. SYSTEM REPAIR-,.... _..
Internal Use Oniv PERMIT#
Li Repair Permit Issued in last 5 years
El . Repair within Boyd's Comers, W. Branch or Croton Falls Res.
Repair within 200 ft. of a watercourse or DEC - mapped wetland
SITE LOCATION 2V c.Ot , r TOWN k er qg
OWNER'S NAME
MAILING ADDRESS 51 QU a R �
APPLICANT &CL ` ay a 0.„ ,n
Name & Relationship (i a owner tenAd contractor
LJ Not iri Watershed -
,Vr,Delegated '7_&A
❑ Joint Review
TM # 195. S-5-3-)
PHONE # -04Jc7f
DATE daQ I 10 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER J aMoh Q 1► Q PHONE # (p it-)) 41tT3 --3071
ADDRESS ?7 &v.-e A1 414f REGISTRATION /LICENSE # l [ 0
r_La ti
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 system)
NOTE: The Department may require submittal of proposal.from licensed professional depending on the
nature and extent of the repair.
0 0 5` /w. t!�:� v� �+tiQ- c7 �-- 1 K K ls"1/ /`'� a a �0 � c.. l ( a C, �N (.- S A C
4z:6.-k- F e� (W s &Lc4- J_- � fi° ®�t.cl tYi G►.'T r�NiJ .44iL.0 .
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE' DATE
(owner)
.I, the septic.install r,. gree to c mply with the conditions of this permit for the septic system repair
SIGNATURE TITLE ��• or _ DATE lb
(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 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.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
re
is in compliance with
Proposal Denied ❑
Datef
of
.codes Yes
F
Y0 /(
Expiration Date
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
UW,1 Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH 'SERVICES FIELD ACTIVITY REPORT
AV,
ICIA MF ' _.•---_ .- ..•..:-- °-.�...--.,.._..°..-' i:- -- - -- .,...�..,,._,,,,,•,__
Street
PERSON IN CHARGE
C1R TNTF'R VTFWFT): C�
Name and Title
TYPE OF FACILITY:
FINDINGS:_
Town
Zip
_.,. 13 �.... �,... t: .... ..._.._...
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TN1;PFC'T0R ` TFT
Signature and Title
REPORT RFC- FTVFT? BY.' _-
I acknowledge receipt of this report: SIGNATURE:
02/96 Title: