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HomeMy WebLinkAbout2850DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.10 -1 -48 BOX 24 02850 lk�5 I 'r M., ELL 02850 yy\X I * I, PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Gi is Internal Use Only PERMIT # ❑ Repair Permit issued in lasts years' V�N& in Watershed j Repair within Boyd's Comers, W. Branch or.'Croton Falls Res. L-T Delegated ❑ Repair within 2oo ft. of a watercourse or DEC-mapped wetland,. ❑ Joint Review SITE LOCATION 14 W rr-3T 5 tk4--- VQTOWN v'rNi A hN A LLayrm # V — OWNER'S NAME T f1 S09 K kL-F-If PHONE # MAILING ADDRESN I %-f W --t S't4.X,F-- ?V rRl+tKV 6L-Li�!6 A -N APPLICANT (A) Vk P- Name & Relationship (i.e., owner, tenant, %nrnon) DATE ILITY TYPE PCHD COMf 41NI67� PROPOSED INE!R L�ER PHONE# d1l Lf 9"Z7 Yl) ADDRESS REGISTRATION /LICENSE # 901: Pro sal (Include a separate sketch a, 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. L-A c-IF C.io LL [µi k o4 C/. -w R e� iJ #G o L- UC VA C k E.:*- rr_ 1, as owner,agree to Up conditions stated on this form SIGNATURE TITLE 0 DATE —XI&W, (owner) L/ 1, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE�� TITLE .,66C(y DATE C (Installer) ProRml SRff_gy29 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 ft 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. Concrete7septic 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 0 Jnspdctoes Signature -& Title Repair DroDosa I is in comDliante with COPIES: PCHD; Owner; Installer PC-RP 99ML Dat6 f .1 Dlicable codes Yes No 0 Rev. 2107 ' 7fiRk Sow kfRsue— I Y6 UVE-S7 St+09F- �A, tor, i qI F Ir NM WOODS Pvmp P,T f oftS - IT« IOlt n\D �' 7'f4(5 o r Roii, 0 PUTNAM COUNTY HEALTH DEPARTMENT v DIVISION OF ENVIRONMENTAL HEALTH SERVICES L� ❑ SITE LOCATION OWNER'S NAME MAILING ADDRESS PROPOSAL FOR SEWAGE DISPOSAL SYSTEM. REPAIR - Internal Use Only 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 /7 0 `✓,VSt She)Y{ TM # 6 ` (jam — y APPLICANT 0 W12 4 ;,'-- PHONE # /% S�� WO T a Name & Relationship (i.e., owner, tenant, contractor) DATE / 6J ,, FACILITY TYPE PCHD COMPLAINT # PROPOSED ST LLER PHONE # ADDRESS 3 L,/ f/ h 4 . y Mt 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 trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional ennineer nr renistereri architect _ I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE TITLE 01,/),t DATE 3 G 6 Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions. Proposal Approved Proposal Denied Inspector's Signature & Title Ddle COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 � v ,, ,,, ., � �, .- " ­5 - �, � , , - , , 'i . , " � , . ; � �, , �­- - , : , , , , - - , , �,�, , I , - " - I'll , , � - � " . . - , .", 4f , � , -,' . 1. -, , , , - .. � """ .11. 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