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HomeMy WebLinkAbout4069DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.67 -1 -1 BOX 31 , y IN IN r �, . kQ ,, . ir L tit 1� IN 0NIL� �. , a PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES OPOg.zlk4a• FOES=. Sf= MfAGE.TREATIV'.ENT:S�YSTEM:':� EPAIR,...., Internal Use LJ 4J// Repair Permit issued in last 5 years ❑ r Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ ❑ Repair within 2010 ft. of a watercourse or DEC - mapped wetland SITE LOCATION �S OS0100 14� -.41 TOWN Pv4MmVatI OWNER'S NAME 1 (d S Q SiG MAILING ADDRESS L.J PERMIT #,,,R Q"t in Watershed [- Delegated ❑ Joint Review 11 TM # '" J NE #�= J—F'"�'� -� APPLICANT L — 11/1(1' L CLInah),-- Name & Relationship (i.e., owner, t t, contractor) DATE 07 FACILITY TYPE c� _ PCHD COMPLAINT # PROPOSED INSTALLER (� �L,C� o� 9,jQVJG'Z PHONE # C1 —7� ADDRESS CL,.. �a, >, �© REGISTRATION /LICENSE # 15 C.:✓�.�'��r 1'7,4 •'✓ � %O� Proyosal (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 extent of the repay. _ d _ _ L _ , _ I, as owner,agree to the conditions stated on this form SIGNATUR � , C� -`-- -- TITLE )*4�) ,& od DATE r _.... (owner) - - I; tt`e septfcgnstalier; ag a to 0o r piy with tine ,conditions °of -this permit for the septi; systel repair - -- - -- SIGNATURE TITLE Did/ -� DATE���� (installer) Proposal 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 Street 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 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 ❑ 7 /v Tins rector's ignature & Title Date 11 el Ex (ration ate / Re air proposal is in compliance with applicable codes Yes 0 No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 d x _ by ; a J v : iVi: a:: , '- . 2 �' T ��s •s; 4* � �- �. � , , ' i '. Pon .. .Y.' 'r� , ° ,y .i , -'i. .i� ' � 4 . .�• Z '�� ' \ �Y^i Y ; ,1�.,N .'; .a . , A�` j° ? '^ti -y.�.� . . ._ . , e.% +� ' '.+ -` � '.i.� � �q^��'1"�Es s'x 3 � , '.; sy�'b.x � ^/ i "'P f 't •, ��S' : o-. J't�k4 ; i r�� �_ 3j�'� • �.- ` �x '.��r. .fys l�� .P , {Y N ] � ._Y " -` x i 'r� i . �+ 2h;yt „ ' � .4a, .. , '�' �y�- ,, ' ' . < ., - . . s � x '"� � £ � M� A F� ' #� � �„'.T'� flW,f ., 5.�. ''.} ,<.,4 r .�li3a .T E .:fx:',� s � ,'s .: ST LUKES LUTHERAN 65 OSCAWANA LAKE CHURCH _ RD R- 319 -09 183.67 -1 -1 PV . __-__._._. 12/16/09; 04/20/10, 12/17/091 0 _ DECLOGG i NO - - ____._...__ _.. .�._._._._.._.... ^_._...._..___ _.__.... ___.._.� __ _.____._.__ ^_..______ _ ■i .r' C118 r