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Home My WebLink About48380�� P QC ❑. ❑ 0 SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT- PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use Repair Permit issued in last 5 years Repair within Boyd's Comers, W. Branch or Croton Falls Res. within 200 ft. of a watercourse or DEC - maned wetland LN PERMIT #i 't�" M - I ❑ Not in Watershed 0- Delegated %/ ' El Joint Review 90 !?I I I Qr&U TOWN TM # lo � �:i1,`Cl� PHONE # C.2C4 11`0 -rR d �,2CG� Name & R lationship (i.e., owner, tenant, ro DATE FACILITY TYPE On,( 4t I PCHD COMPLAINT # PROPOSED INSTALL 6R' 7.yArn.P,j &4 G Ir'01GJy PHONE ADDRESS 3� 6arno, ,R,-, rn Pd Ra )i I n.G REGISTRATION /LICENSE # C &.3 ) Yvy r S6 Pro sal (I nclude al � 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 natreet6col an extent of the repair. n Gt- _— I, as owner,agree to th condfia � on t s form o,,,,) �2 ©S i117 SIGNATURE TITL DATE (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE (Installer) Proposal he following 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 5 completed SSTS repair will function. �No completed work is to be backfll!pd until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Denied ❑ 3ture & Title Date Expiration Date is in compliance with applicable codes Yes O No %1 COPIES:. PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 i - -- - - - - -P.-