HomeMy WebLinkAbout1679DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
35. -3 -17
BOX 15
�. ir
01679
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION-OF ENVIRONMENTAL HEALTH SERVICES ® a
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR !
._...�n,_.... - - - -- ...YES - .NO....�. .:Internal Use Only
❑ Repair Permit issued in last 5 years ❑N t in Watershed
❑ 0, Repair within Boyd's Comers, W. Branch or Croton Falls Res. LS Delegated
0
SITE LOCATION
OWNER'S NAME
.. MAILING ADDRESS
Repair within 200 ft. of a watercourse or DEC - mapped we ❑ Joint Review
�a l3i /m RC4 TM # ?j
App Ae er PHONE # Alj �7f 9y1L
13 7 �f!A 114 A „-/3evi
APPLICANT .,Josrnc5 Ao / /Oct 6z5v 7Lp3C. 4v,7 6,4/-r 1-7/?
(i.e., owner, tenail contractor)
/k
DATE d -� y FACILITY TYPE PCHD COMPLAINT # 1'7 4
PROPOSED INSTALLER �Me3 �� ��-� PHONE # �fr81'T j�73
ADDRESS 37 Gt+c '41- REGISTRATION /LICENSE
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 260
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
CSIn
I, as owner, or rennrt ed agent /of owner agree to the conditions stated // on this form
SIGNATURE / TITLE Alltl DATE
1. Procurement of any Town Permit, if applicable.
2. Submission 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 components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in acc rdance with the
above proposal and conditions.
Proposal Approved Proposal Denied
i spector's Ignature & Ti Date
COPIES: White (PCHD); Yellow (Town BI); Pink (installer), Orange (Applicant)
PC -RP 99ML
Rev. 8105
�y
�a
� Ktrs`
I ,
"F Yy rai
r
4 .F
' N.K
f
k �u.
�a
'M.
l96
ev. .
t ofthrs report:' :.SIGN ATFURE
Title::
v
:
Y i
I
t
--
f Y
i
,
�
I
ure and Trtle
t ofthrs report:' :.SIGN ATFURE
Title::