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HomeMy WebLinkAbout1624DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34.13 -1 -15 BOX 15 I IL ML, I . :1 - I is 01624 PUTNAM COUNTY HEALTH DEPARTMENT O a DIVISION OF ENVIRONMENTAL HEALTH SERVICES K..-P__R.OPO.SAL .:PO.R SEWAGE_TREATMENT.SYST YES N A+0JOW Mh teal Use Only PERMIT # SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT / / /Repair Permit issued in last 5 years El Not in Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res. �elegated Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review ty 2b LZ iy'6-7T. TOWN TM # a)(A . PHONE #�� DATE z4 Xg zl-e— 5P PROPOSED INSTALLER ADDRESS FACILITY TYPE �'G$ - PCHD COMPLAINT # (—&,tsj�H0NE # a_?, 2q STRATTON /LICENSE # 3 a, lv 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. y�lcu.e x /�Ic -s�'2 f�'� Y,..s i ©d� tiwllo,, C�.ieIC ,f �k' I, as owner,agree to the co cc ted on this form SIGNATURE [tom TITLE DATE (owner) - - - - - 1,- the - septic- instalter;- agree -to com -ply- with*e= conditions -of this permit for the -septic • system ••repair -• -- - » - --- - w- w SIGNATURE ITLE DATE /O (installer) Proposal approved with the followi nditions: 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 osal A ov Proposal Denied ❑ I spector's Signature &Title Date Expiration ate Repair proposal is in compliance with applicable codes Yes i No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Oct 27 09 04:24p Tyndall (845) 279 -5989 p.3 ti r ID 90) . � r 1 a r - --�il� r%— � u,�;�_1...5 //I r"'- -� J � ill. `� !' � �/ � v ► � _.