HomeMy WebLinkAbout4837PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use Only PERMIT #�'
❑ C Repair Permit issued in last 5 years ❑ Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION _ a� Pall 1 I e TOWN a TM # ,lei a.N a. (� 6�a4�
OWNER'S NAME PHONE # A q no
MAILING ADDRESS ` b , ULL
APPLICANT 0 L Lye-
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER PHONE #
ADDRESS REGISTRATION /LICENSE #
Pro sal (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 I I I Imo, (4-4 C - I q [ 10
I, as owner,agree tcondmons stated on this form
SIGNATURE TITLE DATE I
(owner)
I, the septic insta j�gr o comply with the conditions of this permit for the septic system repair
SIGNATURE TITLE 0 A-ti DATE
(Installer)
1. Procurement of ahy/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
Proposal Approved Proposal Denied ❑
O 1.
Tnsil6ctoes Signature 8 itle' D to Expir do Date
Repair or000sal is in compliance with applicable codes Yes C' No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
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