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HomeMy WebLinkAbout4828f PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES V PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use Oniv PERMIT # /T -dc ) c ) — ❑ Q/�e 'r Permit issued in last 5 years �❑l Not in Watershed 11, ®' epair within Boyd's Comers, W. Branch or Croton Falls Res. �h' Delegated ❑. Repair within 200 ft. of a watercourse or DEC - mapped wetland (❑ Joint Review / SITE LOCATION l OML TOWN Pc ti o• TM # �j tp OWNER'S NAME 2d�,�r� LC M8 PHONE # MAILING ADDRESS -70L L ^�5�' Alrc,4,� to, #4450tH J lt/ I LS' -43 . APPLICANT &04 er+ C-WA o O V4 h Q V Name & Relationship (i.e., owner, tenant, contractor) DATE G FACILITY /TYPE Q$ e n PCHD COMPLAINT # PROPOSED INSTALLER (�� _ PHONE # ADDRESS 37 6: 1111 -1 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. I, as owner,agree to the conditions stated on this form SIGNATURE ��� C� TITLE Q wi, DATE (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair I SIGNATURE 4el;e TITLE f�� DATE (installer) Proposal app ed with th ollowing 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 Pro osal Approved all- Proposal Denied ❑ Inspector's SiOndrure & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes 0/ No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 _ Sheet 1 of 1 S T Putnam County Department of Health Division of Environmental Health Services Field Activity Report Name: B Cuomo Telephone: Address: 706 East Branch Rd Patterson NY 12563 Street Town State Zip Person in Charge or Interviewed: Date: 11/29/11 Name and Title Findings: R- 253 -11, The septic repair was done as per permit. Replaced 4 D- boxes. Inspector: �., � G iv A Telephone: Signatur, d Title Report Received by: I acknowledge receipt of this report: Signature: Title: Field Activity Report: cw Date: 555- ,05 Flk13i' 'F2 I A 4F a i �,a�'uT a'ac a'2�.l;�b °` r.. i`•�'>ye�i''''�n`.,,. r 4r '3% v.}r �^J� �rkZr'�5 sg"� u1��awbT is k, a : i r` �� ��n1 N iP w � RWM PL S �°d9 $19t •!v1�d4 � z a sri,,l � �"+ � �,'�'""' Kl s s{' r �� f'� 4}, 3 �' '' u'Y'l � '?et -X�� r �,,o� a'- � ..1t ^.� fit, •�''� l � �� �.^ � � � I � a f ;,� Xy 1 Av c irlk4;t f c t y 14 t W$T Y4i `'3. .may. .. Gt�/ R � L ` +� r��'> �� � � ! , 7 c;. t i .t,,� '•., Y 1 1 ,, 3Y ''.. °„+ -,4� �If t � };7� � ✓��' i,r •A � �A f � s'�i ? , .,� � � ''V 1 isoF��.,h tiw. "'�4'Fu �'�' Yi � i AV., Y` G�'i •, �4t °"•1 t a.r �t tul iC y � lot •i e�T,�t1r a 1 5 �� j T S a• t, NIUE top Z y i 'fj� Ln i,u X. `1� +( ' i M1M fli3titi Sl i a �.. ;_. {'4 `E,+ YIU��si� +1t1�7. ill w. l \ / �•l � z: �+tS'7''�. '= 4�,,�- ��-�'4� "�i� ,�c`" §� '1L�F'��'v �1 �i.n .�r +l• �� _3P i'{'� rM1�`>�o,,1'i �. �f��� 7Y ' �. 1 �, ��•`ez7�7, ; \'{1��fl�j v4�;� y-•� . /;� is Y is 3 K�qI r: t :"f • i t F t. L Yt s ick - y� RX t�rt�,'rw . �+1 � Lv:`"�a,11Y {ty� #r`(� r "„';,�_. •`}F� � �' 1 6 ' :' I i.. rte.