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BOX 33
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04370
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O P -1 PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
;:.;PROPO:SAL FOR-SEWAGE TREATMENT SYSTEM. REPAIR,
Internal Use 0
PERMIT-#
U Repair Permit issued in last 5 years k3a Not in Watershk�
❑ 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
SITE LOCATION �9D 'T60T'1.W_L 4 fTOW N
OWNER'S NAME
MAILING ADDRESS
APPLICANT
'I t #
PHONE #
Name & Relationship (i.e., owner, tenant, c ntra4 ctor)
DATE 0 FACILITY TYPE -�_; PCclHD COMPLAINT #
PROPOSED INSTALLER PHONE # lk-
aC (a e S C /�vv4
ADDRESS �_V_ N/g. y,-,- 4j({ LL - REGISTRATION /LICENSE # Joy-3
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 extent of the repair. -7-.4 14 /_.
I, as owner,agree to the conditions stated on this form
SIGNATURE �a� �.�I TITLE d'K'W C,UZ DATE 5/2-t bo
(owner)
.M= � 4,- the*septie -int � 4ee'fo comply ith the conditions of this pe�n�it�#or the septic system repair 4=
SIGNATURE TITLE DATE a
(installer)
Proposal 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 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.
lill�i�L•191��7 �ICtli I + "1
Proposal Approved Q� Proposal Denied ❑
Zs D
Inspector's Signature & Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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