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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
£" •r`
YES NO i Internal Use Only PERMIT #
❑ Lr'' Repair Permit issued in last 5 years U in Watershed
❑' epair within Boyd's Comers, W. Branch or Croton Falls Res. IR Delegated
❑ l Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION r' /r r �' c�,� . TOWN I TM # o� J� Z
OWNER'S NAME '� %� ---:5 PHONE #� �.. �� ,n
MAILING ADDRESS �X/ �)- S / AR V I
APPLICANT
Name & RgWonship O.e., owner, tenant, contractor)
'DATE',-` FACILITY TYPE PCHDCOMPLAINT #.
PROPOSED INSTALLER . A /ice PHONE # %/y.-Vak02Y/
ADDRESS 04 ,,. rZ, REGISTRATION /LICENSE #
Proposal pnclude 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. / I �C fi r;:• �^
n k G[° S/iC'e %gin r+ / / /ape 1 L—e
i, as owner,agre ,9Ao the conditions stated on this. form
J
SIGNATURE " . ; / ,d/ TITLE .f,.r' DATE��/r�
—�,
(owner)
I, the septic install ,agree to comply with the conditions of this peJjrmitt� for the septic system repair
SIGNATURE TITLE DATE.�i
(installer)
1. Procure"rit 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 1
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
Propos l A roved
rui
Lp, Proposal Denied . ❑
1
Inspector's Signature, ✓i'< Title D to I Boiratlahn Date
Repair proposal is in compliance With applicable codes Yes 13/ No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
S
IR
OWNER'S NAME 1/G �? o• /!� / JLo �! °� MW - :1?- �p Q
SITE LOCATION �`� ,c %/T o y, �� -� c� :-D-�'i c/,o 'Ilri
MAILING ADDRESS
PERSON INTERVIEWED w f PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE Z TYPE FACILITY
PROPOSED III (f7> rem -7 -e:; -r— PHONE
Proposal (include sketch locating all adjacent wells):
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.'
0
.__._...^ s �,m�� G a
Proposal approved
Inspector's
7 � 9z-
te
roposal approved with'the following conditions:
1. Procurement of any'Town permit, if applicable.
2. Sukmisgion 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 cagments tied to two fixed points (e.g. house corners).
d. System description.(e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
PUS: V&te (PAD); YeUcw 03n HE); Pink (Applicant)