HomeMy WebLinkAbout4206DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.80 -1 -68
BOX 32
&,:RL r? r
1
IN IN
,. �
Ir
J 1,
�' '.
r. Y
SITE LOCATION
OWNER'S NAME
MAILING ADDRE
APPLICANT
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL -) EALTH SERVICES
J:
Internal Use Only PERMIT #
Repair Permit issued in last 5'years ❑
❑ Repair within Boyd's, Comers, W. Branch or Croton Falls Res. ❑
❑ Repair within 200 ft. W a watercourse or DEC - mapped wetland ❑
V'LO� �o
, f tl
WIR
Not in Watershed
Delegated
Joint Review
L� P-6_'n S TOWN 'r Ltl<r TM # �3 °il0 ^ C�
1 Std M1'1 !mil D PHONE # el 9 S'S -, S9f
� c� � i' � t c �a� � • . ` �' 7
Name & Relationship (i.e., owner, tenant, contractor)
DATE I t AGILITY TYPE PCHD COMPLAINT #
'PROPOSED INS � R SC + (,,� En PHONE# Res ,rte arc
ADDRESS -rM #0 REGISTRATION /LICENSE # io I-3
Pros. sal pnclude a separate sketch locating the house, property lines, all adjacent wellls 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
I, as owner,agrpe to the conamo states on mis Torm
SIGNATURE TITLE DATE 413 It
(owner)....
I; "the septic in sta er,'agree to/n�comply with the conditions of -this perrhit for the "septic'system- repsir
SIGNATURE . �.c-�J TITLE 46 f ,+c, t DATE 1
(installer
Pr000sal aooroved 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 SS TS 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 ba7lled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Pr I proved � Airrlwal Denied
tG
Inspe or's Signature & Title Date Expiration Date
Reoair DroDosal is in compliance with al) Dlicable codes Yes No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
a.s
24ME
<left
Tb
t4s
hc
� � 6
j4 (-E TACK/ S' u �9 c-t -s c t� v _ I L 'L 9 C C. is f, ft ST, 1.04( -cc
r f s�. N.y�: �.a.�• -•- .�:_rJy�..fV � 'r ^,per . /•:X � >' m �.�ev. •-.� -- o v . , n , .. _. ..� 6- u>7:�. -i-:c �.n.. n. - ....�'..re_ e
L(L
6Uf °-
p
ID.
s
s59 S
Q, Lill
To IZ tic F kip- 1,r�'
F— C)
—1y'
f O w
P `
VJ/, L L