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HomeMy WebLinkAbout1955DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.30 -1 -13 BOX 18 01955 IN IN me 610 IN . f IN NIN ON ONE ENO' r 01955 �q rat.+rtsar:W :u�. ►z.. mac* A PUTNAM COUNTY HEALTH DEPARTMENT 310N OF. ENVIRONMENTAL HEALTH SERVICES MRR U VRepair Repair Permit issued in last 5 years I-1 of in Wat ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review �1 SITE LOCATION o2- r,- de4k ( ox TOWN TM # ' © — DV � � r3 OWNER'S NAME —.2C6 (, ;,, PHONE # MAILING ADDRESS; APPLICANT Name & Rel onship (Le pvmer, tenant, contractor) DATE FACILITY TYPE - PCHD COMPLAINT # PROPOSED INSTALLER PHONE #,S ADDRESS 110 / REGISTRATION /LICENSE # 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. L = as..owner,agree.to. c, :tag ondifions stated -on this forme SIGNATURE TITLE DATE (owner) I, the septic installer, agree to comply with the conditions of this. permit for the septic system repair SIGNATURE. :. __ _ f TITLE DATE (installer) 0 ov d with The fol o c ndi io s 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: t 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 fimction. ., . •`QWHMj fbra work is to bb backfilled until authorisation W do so has been obtained from the Department. INTERNAL USE nmi V Proposal Approved Proposal Denied ❑ ALA /O Z,27 f/0 7 inspector's Signature & Title- Datd I Ex iration Date Re air proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH ,.: _DIVISION OF- ENVIRONMENTAL IIEATLII SERVIC-ES{ Y FIELD ACTIVITY REPORT NAME: 1,AiJE— TPi• Street Town State Zip PERSON IN CHARGE nR INTERVIEWED; 2!;,Z /;L,/// Name. and Title TYPE OF FACILITY: 'Sflml� LWOW L� Signature and Title RF_P_ORT RF.0 RTVRT) BY., I acknowledge receipt of this report: SIGNATURE: 02/96 Title;