HomeMy WebLinkAbout4236DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.81 -2 -27
BOX 32
04236
is
` h'
T
J'.r"
Vo
04236
/mJe v
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES 41 S-0
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR -UT /(��/
.. - • . �yv.� y'.i .. r f \. , . \ -. .:?i'J.£'
YES NO a/` Internal Use Oniv ^�
❑ U/ Repair Peimit 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 wepand
❑ Joint Review
SITE LOCATION V A H �l�0 TM # 9-q is j- CA- C'
OWNER'S NAME lotik ff£f2RfRAr - A 4 ,iyto PHONE # S1r5'•- 5- 92-.37��
MAILING ADDRESS -cif ?tEkS'fc�!
APPLICANT -14 U/,4*LQ G F AtS £R T-
Name & Relationship (.e., owner, tenant, contractor)
DATE /I i Q FACILITY TYPE PCHD COMPLAINT #
CuLlg /v Iri 3F Y?
PROPOSED INSTALLER it-b � C1 T PHONE # 9PS7 S-ab -c4 FFS-
,�L% 45"IV.4k,+
ADDRESS I?„ ti-p. ogg, V ik -e-Lf v N REGISTRATION /LICENSE # PC I g
110.5 Jy'
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.
�Si Z►7� �Yt1: � =i E :E 7;
4f,
I, as owner, or rep rted agent of owner agree o e I onsns ed on this form
SIGNATURE TITLE /�G49A-11-
Proposal approved with the following conditions:
1. cerement of any Town Permit, if applicable.
62. S 'bmission 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 i accordance with the
ve proposal and conditio
Approv Proposal Denied
,
I 1 L �
In pector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
De„ amr.
DATE 1
E!
E�
Q
lzepb -c-E 'Ftu dv, -- a use �t�l
ii
416 4L'OV
f=
12�rr'
' F�d 4 dam'+
ketz
u,}
W e a D -
E!
E�
(i
M
ii
x76
PC
La- .e , 'r r. r. ._ .... .. ,. .�. r.�. >r.'� ._. js•: :.. J, � ..K -. x. �'L _�C+ .. .... s .. ... 2 .. ... `!inv.X .�., ,.��:'i ..p'.:-- .t: -Y.. :� ;. ,n :'�..
LEwe- 5 sr, (C.
�t-
�'�