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04776
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION -OF ENVIRONMENTAL HEALTH SERVICES
`A 'F Ai ' 'TffE-' i ►T M' Ri l R y
YES NO, Internal Use Only PERMIT #
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❑ Repair Permit issued in last 5 years -99 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 wetland r1t ❑ Joint Review
SITE LOCATION (SarnZ. TOWN �k4 L.SiC;1 L(,, '( V TM #9 j. , 2. (a a. — 4
OWNER'S NAME r.ANDAGiP I N 112L PHONE# PLI r- S-2B-2LJ vS_
MAILING ADDRESS 10. H.A223� 5; LAKE MEmi-A IAi,, bJV 10T- 17
APPLICANT CA1V'014-014 W' > dM
% N e 11 Relationship (i.e., owner, tenant, contractor)
DATE / _"7 110 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER Ti m (�7 U a, L44 er 61 PHONE # 0-6 3 Yy
ADDRESS 3l CoL i,, �,,,� ALL) Ajr U EGISTRATION /LICENSE #
Proposal pnclude 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, as owner,agree to the conditions tated on this form
SIGNATURE C -TITLE (A1,� DATE t �7 ' 6C�
mv......rJ_...... . .. ... ... -w .�v.. tom. ....c�..w. b' -.+. .+.v._.. ....n.. w .- ...�.. .,...• .. .. v- .4- -....� .-Y�.- � ..yrUV._...V._p M. - .,y�.w.
I, the septic installer, agree to the condfioris oft tls permit for the se�ttc system repair'
SIGNATUREO � TITLE 9(cs DATE 27 0
(Installer)
ProMgRpmy d 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 bed 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 ft 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.
1:1t4:1L'0X1RL4D1LM
Proposal Approved � Proposal Denied ❑
9/,V_ O at .- 7-S
Ins or's Signature & Title Date 1. Expirfition D to
,Repair proposal is in compliance with applicable codes Yes S No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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34-Columbus AvePutnam Valley N.Y: 10579' -914-760 6344
Candice Winter TM 9126 24 Date., 10/22/08
�Harper Street License# 1137
ake Peekskill N.Y. 10537 Septic repair
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