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HomeMy WebLinkAbout2750DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -1 -14 BOX 23 J or 'i I I ■ E .� L r ` 02750 PUTNAlA COUNM` HEALTH DEPAR T IAENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0 _ PROPOSAL r=OR SEWAGE TREATMENT SYSTcM REPAIR YES 0 Internal Use Onl PERMIT #t j I epair Permil issued in last 5 years ��Die'legated f in Watershed Repair within Boyd's Corners, W. Branch or Croton Falls Res. Repair within 200 fl. of a watercourse or DEC mapped wetland ❑ Joint Review IT LOCATION��►J�� �fyliLDN/R OTOW N �J/i TM 4L2M � J-- -WNER'S NAME PHONE P 9 _2� /J IAILING ADDRESS #z!q 17'044,Q ,Q fl !%TJi% fi 7cf PPLICANT G2� ,Cr/ �u/I��� Name & Relationship (i.e., owner, tenant, contractor) SATE �� d FACILITY TYPE �L INO� PCHD COMPLAINT 'ROPOSEDI ALLER Q � O� i2 /T/6T t� PHONE #1 S�S'�G� z�3 6j .DDRESS �/ %�lLltl /_REGISTRATION /LICENSE # ?' 5'70 r000sal (include a separate sketch locating the house,.propertylines, •all:adjacent wells within 200 :et of repair and the location of existing and proposed system) TOTE: The Department may require submittal of proposal from licensed professional depending on the ature a_no extent of the repair, CAL as owner,agree to the condltions stated on this form SIGNATURE TITLE DATES:. owner) h peptic ifisia(iE� 'aar e to comply wth,the- conditions ofi.this�pp►mlt,fic;�t` : ep is 5�isieni= ;:Pia r - - - , ,IGNAT�FIE TITLE /� DATE Ze _Zql installer) 'roposal approved with the following conditions: . Procurement of any Town Permit, if applicable. i. 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 Tar, 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 I. 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. X INTERNAL USE ONLY Proposal Approved nspector's Signature & Title Proposal Denied Repair oroposal.is in compliance with applicable codes COPIES: PCHD; Owner; Installer PC -RP 99ML ❑7 _ZP 30 og Date Yes El Expfratio6 Date No 2X Rev. 2/07 I r r. V ov PIZ. Ali - 11 om.0-S l')© W, r i- /- -S ---4 AHA� FRAI-01`1 ig P,