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BOX 28.
03597
1
Lima
IN --k
IN
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03597
SITE LOCATION
OWNER'S NAME
MAILING ADDRE
DIVISION OF ENVIRONMENTAL HEALTH SERVICE:
bnternal'Use Only PERMIT # -U b
Reps Permit wed in 189t g years of in Watershed
Repair within Boyd's Comers, W. Branch or Croton False Res. Delegated
Repair within 2001t of a watercourse or DEC - mapped wetland ❑ Joint Review
s v7-rZO-P yLeOWN `�'k)r -Rjdm V u CY TM # 'k7 i; to T l --/
U t PHONE # 14- rer tea¢ ,V) 3-7
APPLICANT +V110 A4110
W
.T— Name & Relationship (i.e., owner, tenant. convacto
DATE 'S ;AGILITY TYPE PCHD COMPLAINT # 7 C-t t- L
PROPOSEDINST
( W F ttq PHONE# 5 qS_ S-
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ADDRESS � Dil/ l (AL �Q� f Oo*EGiSTRATION /LICENSE # Pm
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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and n o the repair
1 .
_U tJ-t C.A -tiACi rill TX1 T- tL T1 2s �9-f
1, as owner,agres to the conditions stated on this form
SIGNATURE TITLE Q UJUlf (- DATE b �
(owner)
1, the septic insm er, agree to with the conditions of this permit for the septic system repair
i
SIGNATURE TITLE 16 , ` DATE 3 g
(installer)
P,sg m-W 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 Stmt 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 cbnditlons
4. The "proposed SSTS repair- is considered a-bidd 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
Approved.
Is in compliance with
INTERNAL USE ONLY
Proposal Denied ❑
D
Date
Yes Cr' /
M
No O
COPIES: PCHD; Owner, Installer
PC-RP 99ML Rev. 2107
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