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. :PUTNAM COUNTY HEALTH DEPARTMENT -
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
NO� Internal Use" Only
❑ Pl,// Repair Permit issued in last 5 years
0 Repair within Boyd's Comers, W. Branch or Cr oton : Fall s, Res.
Repair within 200 ft. of a watercourse or DEG-mapped wetland
PERMIT O
Xj
IR U
Lad' yNot in Water
Delegated
❑ Joint Review
SITE LOCATION TO . Wi4vV `-r - 4E TM1#51dV-1-a1
OWNER'S NAME Ck S, F- A (c K5 C H '-91+7pt &4!4 I�V� ONE # YS—S 2.9- cl 0 2-
MAILING ADORES C,4k.0 er- IqCL i PV lte,4m
LLV
my 1 .101 7
APPLICANT GW tz
(0P,4C0CPf ... :
Name & Relationship Q.e., owner, tenant, contractor)
DATE FACILITY TYPE
PCHD COMPLAINT #
?
PROPOSED INST4LLER 40 CVA&,0 6. 966 EX r-' PHONE # C3�y 4 9- 7r?_ 'I 1? 97 C
gq& 0Sr_A_&V,4,N4 - L.r_
ADDRESS A
U CLjFV.N1-, —REGISTRATION /LICENSE# /QZ2
I I I 16S-Iq
Pro sal (Include a separate sketch locating the house, property line$, all adjacent wells within 200
feel: 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.
as owner,agree to the conditions stated on this form
SIGNATUR TITLE.. W�£'a DATE jo
(owner) V i
1, the septic instal agree to comply with the conditions ofthit permit for the septic system repair
SIGNATURE I ITLE 1.
DATE I
follcm
ove the following conditions:
Proposal m2gamWd *
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.duplicalle showing'
a. Owners 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 "1. 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 his been obtained from the Department
INTERNAL USE ONLY
Proposal Approved L Proposal Denied
Insfwor's Signature & Title Date 1xpiration Date
,Repair proposal is in compliance with applicable codes Yes No 0
COPIES: PCHD; Owner; Installer
PC-RP 99ML • Rev. 2/07