HomeMy WebLinkAbout2251DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
41.06 -2 -17
BOX 20
1
.,
64 .
J '
T
L
oil
ALP
i I
02251
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
%
YEa NO Internal Use Only PERMIT # 1 \ e 1
❑ Repair Permit issued in last 5 years Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
9 ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADC
APPLICANT
ySl
TOWN I urn��i �f TM #�,
PHONE# 5/6-5%9'55/6
DATE / /_ / y- // FACILITY TYPE R F 5iD _ wcF PCHD COMrrPPLAINT #
PROPOSED INSTALLER ' k-6 6, 45o r. M-, PHONE #
ADDRESS 44o4Z REGISTRATION /LICENSE #
j� Cej $�
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 2f) THI) 5'0 W
feet of repair and the location of existing and proposed system) SI 3T
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
iA <1 Q:Aw40 ec:� 1p i % i' k in&i_) C,. �C_i "�' �0Cam+�' Qtt �'Cit
I, as owner,agree tQ the conditions stated on this form
SIGNATURE TITLE DATE
(owner)
1, the septic installer.; a ee comp) with the conditions of this permit for the septic system repair
SIGNATURE TITLE 111e_5 DATE AID"
(installer)
Proposal approved with the 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
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 0 Proposal Denied ❑
z�� lt) 9=S4 �, &OE &&��Zz� /—//,
In pector's Signature & Title Dide EdpiratiorfDate
Repair proposal is in compliance with applicable codes Yes lJ No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
............
d t
Al- -1 -1-1-1-1—
ry
C-v
ry