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04775
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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YES NQ Internal Use Only PERMR - #�
❑ epair Permit issued in last 5 years t in Watershed
❑ . Repair within Boyd's ' Comers, W. Branch or Croton Falls Res. Delegated
El Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION S1_ TOWN 7*#J L_ TM # 2LO
OWNER'S NAME MPny R LLF, N H F— i ,- o PHONE #
MAILING ADDRESS 00 Z`6 6Ar LAA lftr * 1, o!).537
APPLICANT >i41 :q-
Name & Relationship (i.e., owner, tenant, contractor) _
DATE D e ACILITY TYPE PCHD COMPLAINT #
PROPOSED I ST� 6Sc � ! P �C� PHONE # ¢fca S
ADDRESS -) - � � U46L,E REGISTRATION /LICENSE # :,0 '0
� tL+4��Yt Y/' �1�.
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.
I L e0) Lu I nos CSC. ea► rL�r
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE (� Ui, //� DATE I D hl
(owner), ..
I- the - septic insl 'per agree to com i' wi'h the'conditions of this' emit iorthe srptic's s`#em rd air •� �- ' F�
P P .y p
SIGNATUR , TITLE �.� � 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,zjuararitee 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
Signature &
Repair proposal is in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Proposal Denied ❑
Date
codes Yes
Expiration Date
C�' No ❑
Rev. 2/07
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