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HomeMy WebLinkAbout3855DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -3 -40 BOX 30 03855 �r4j� �z YES NC SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT 4(5-0 -J G PUTNAM COUNTY HEALTH DEPARTMENT • DIVISION OF ENVIRONMENTAL HEALTH SERVICES vqa Internal Use Only Repair 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 5 0RUt ARO R TM s-3 t 1 —3 -11e 11 E (.i s0 �``0 PHONE-# it ;?,;L92- .61 �y ) Q T- M VA, i,t_ 2_ I °S'Z2 0 r.— Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER p W A PO GPAJO F Xo l PHONE # ADDRESS �C%® �1�CR�i%N04 C�I�. jZ y, REGISTRATION /LICENSE # rC 139 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 registered architect. IZZ ^LA C E .S'7 8_F_ (.- T/4 N K iAJ //\I E W 10 o-a J r_,a A rqn F1 rr-c DJ wt � �+ rW_ f'I I c ,4_e7t*C, T I/ b6/ d 5' °%k- 5",t coves fe-, Cep -)ue�- `"o% vcod r I, as owner, or re orted agent of owner agree to the conditions stated on this form �' ui'ur SIGNATURE aj TITLE ,Ct ---r DATE 2,r Proposal approved with the following conditions: . Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owners 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 conditio Proposal App` ve Proposal Denied Co Lo (0 spector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 -D l� LO oL,3 h A r'► �tal �h PVC T t6 rt •r , 0 r mr, c u C, V e tL f' AV A C•1S ? -O w 056 MQ W "thOte-, /goo C0,4G "IJING ?3.4ct< Sao To 6,e r `0 �� K fNtr t6 g I on ®" f- i 6 tfT S'w 7-0 ttl3U4-1j4dW 0 rt,-f-a �7— 1*44 1,/ -r-NAAL V4 L-'L-�y I IV 10-5-7er' A PC I 40S., 6. 11 /000 CA-Z- OX-4-LRL-rS7,- - rfL Lf J6 C- 77Y 'Z)" r- r-L -t- (L To t 6 OeAV e I� � f ��ry N b (4 c r-7 ' E3 c - ( 3 ' , -nn- Ivi< jj-D eA 61 M - -2 -7 '61j VU -r -NA#PL L/4 I IV le S'7i � CAc 1D c 1 3 -,Vj� Lf s- l V �b k �.a KD Or l