HomeMy WebLinkAbout3031DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
62.18 -1-46
BOX 25
03031
1 11
IN 11
' r .
�i
''
No'
No
IN
1
IN no
Ng
7
46t.
I
I
IN
1.
go
r
IN
I
03031
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
3 NO Internal Use Only
❑ ❑ Repair Permit issued in last 5 years
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ ❑ Repair within 200 ft. of a watercourse or DEC- mapped wetland
SITE LOCATION
- OWNER'S NAME f /J`tJ /A&j
:;q2 MAILING ADDRESS , es e2 C77 Co,, /Z
❑ Not in Watershed
❑ Delegated
❑ Joint Review
TM #t > -<- f � I ,/ iVC
PHONE #f1y-2 -?/ — I �, rf
/ 11�4-mom /o.S- j
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER?,,; �►� S „�,yir Li, N, 1 i „.r y° PHONE # '7.3 1�eQ
ADDRESS i�j fib r�.�� S'I 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
engineer or�engist/ered architect. / 47""4- /'
1 �C rOIGt�C ��bcr 57-i s�l w'i M�1 (00 0 -e-A0,,
I, as owner, or reported en f owner agree to the conditions stated on this form
SIGNATURE TITLE DATE
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 ac rdance with the
above proposal and conditions.
Prooasal ADDroved.., ,,n ProposalDenied
4 / Allo 6
Ins ctor's Signature & Title bat
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
-13 4-11-
12