HomeMy WebLinkAbout4848PUTNAM COUNTY HEALTH DEPARTMENT
pIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYST
YES Internal Use Only
❑ Repair Permit issued in last 5.years
[ NO J Repair within Boyd's Corners, W. Branch or Croton Falls Res.
E V Repair within 200 ft. of a watercourse or DEC - mapped wetland
SITE LOCATION 37 Se i CAN TOWN OWA VR ii
OWNER'S NAME
MAILING ADDRESS 3-7 _S2r —e. PufNAW IIA,
APPLICANT �EF-2�i
Name & el
DATE /0/11111
PROPOSED INSTALLER J.
ADDRESS
(i.e., owner, tenant, contractor)
FACILITY TYPE
C
PERMIT
El
TM #
PHONE #
ED
Lr--� -
Not in Watershed
Delegated
Joint Review
A
_, 3
0
PCHD COMPLAINT #
PHONE #
TION /LICENSE # 1 O 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, , i — ,
I, as owner,agree to the conditions stated on this form
SIGNATURE a ITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this.permit for the septic system repair
SIGNATU TITLE` DATE / 04�
(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 Tar, 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 backfilleduntil authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved
nspector's Signature & T
Repair proposal is in
Proposal Denied
ance with applicable codes
/,9ZZ
Dat
Yes
ration 'Date
L7' N o ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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comparable;
Municipality of Putnam Valley, Town of
864 sq. ft.
First Story Area:
SWIS:1
372800
ITax ID:
1 52.-3-60
0 sq. ft.
Additional Story Area:
0 sq. ft.
Three-Quarter Story
Area:
0 sq. ft.
Finished Basement:
0 sq. ft.
Structure
Building Style:
Ranch
Number of Baths:
I (Full) - 1(Half)
Number of Bedrooms:
2
Number of Kitchens:
2
Number of Fireplaces:
I
Overall Condition:
Normal
Overall Grade:
Average
Porch Type:
Porch Area:
Year Built:
1963
Basement Type:
Full
Basement Garage Cap.:
2
,Attached Garage Cap.:
0 sq. ft.
Area
Living Area:
864 sq. ft.
First Story Area:
864 sq. ft.
Second Story Area:
0 sq. ft.
Half Story Area:
0 sq. ft.
Additional Story Area:
0 sq. ft.
Three-Quarter Story
Area:
0 sq. ft.
Finished Basement:
0 sq. ft.
Number of Stories:
No Photo
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http://Putnam.sdgnys.comlpropdetail.aspx?swis--372800&printkey=052000000306000OO... 10/17/2011