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HomeMy WebLinkAbout4425DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.11 -1 -34.2 BOX 33 �,�,. ; I y ki I �' ` 4. ;i E ti j 04425 a PROPOSED INSTALLER LOCO l Gl % e flJW161 -fa PHONE # V YS- '��6 aV7 � ADDRESS :3 1w AtK -PzLAW REGISTRATION /LICENSE #30374110a 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 I, as owner,agree to the conditions stated n this form [� SIGNATURE TITLE DATE W (owner) I,-theseptigJflstaHer;a o co plywith'the conditions ofthis pi rmit.fdrthesept]6system repair SIGNATURE TITLE, ELQ , DATE (installer) ProRosal 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 Q Proposal Denied ❑ /9 Inspector's Signature & Title D616 Expiration Date ,Repair proposal is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 n -PLITNAM COUNTY-HEALT-1 EPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All Information below. must be jUlly completed prior to any scheduling SITE LOCATION grlh, I TOWN.PUTfAW �A�) TM # OWNER'S NAME -Toloc> PHONE# -797- �3- MAILING ADDRESS iv�- PROPOSED CONTRACTOR/INSTALL ER 1,cacn-1 6� PHONE #,V(/,fS-)6W7/ ADDRESS REGISTRATION /LICENSE# '3aS7A-/10-X-3 82Mn for exalondign: �Pallure to surface $r- back-up In house ❑ find limits of system for mpaIr P9 other (explain below) Date Date: 41 Time: U kly:excekseptic O• E PUTNAM COUNTY HEALTH DEPARTMENT" DIVISION OF ENVIRONMENTAL HEALTH SERVICES � - 1'F OD _.. .PR ,NT S T h„R P OPL Y- SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT internal Use Only Repair Permit Issued in last 5 years Repair within Boyd's Comers, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC- mapped wetland TOWN iJr^>P1 # t"\ -r-4" `-I -- U Not in Water, M Delegated ❑ Joint Review TM #...Gy,1 \- tl - e� NE # ZY-7 -> 0:1 `/F'& Y Name & Relationship (I.e., owner, tenanC contractor).) DATE / sO FACILITY TYPE PCHD COMPLAINT W PROPOSED INSTALLER OG�q y plum PHONE # ADDRESS REGISTRATION /LICENSE # 3'Q 374 /0.) 3 -4/1 cf y�-iWo)� Pr_ oposal (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 I, as owner,agree to the conditions stated�n this form SIGNATURE 1 ° ;,� �' 1 ,^ } �-- TITLE ;'t -J+ C� DATE C (owner) ' I,:the septic.installer; re .to co �? .� itlt e�conditions of.thi perttsii foctfi®.Gspti :system ep ii __ =:.._ - . . - -� -- _. - a9. 7-[SIGNATURE iT : DATE /S (Installer) Proposal @poroyed with the followi:Qq conditions: 1. Pmduremeht 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 061rits 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. f' INTERNAL. USE ONLY Proposal Approved Proposal Denied ❑ Inspector's Signature & Title ' , I IIDU Expiration Date Re it proposal Is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 40 I._._..._....._.._ A ,79 31 a1 qtr 5-Y Local Plumbing / Drain Inc. "Finch Lane Lake. Peekskill, N.Y. 10537 Tel: (8= q I 526- qj oc �j 247,1! )NS,7pfq 1000c rjq / CoAjc4A,TC- bra, c. —/,.,Jk-- C 0 #lJ AJ -C<,T Tc� F-i -tl d A ------------------ V4V o sB A ,79 31 a1 qtr 5-Y Local Plumbing / Drain Inc. "Finch Lane Lake. Peekskill, N.Y. 10537 Tel: (8= q I 526- qj oc �j 247,1! )NS,7pfq 1000c rjq / CoAjc4A,TC- bra, c. —/,.,Jk-- C 0 #lJ AJ -C<,T Tc� F-i -tl d A ------------------ V4V