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HomeMy WebLinkAbout4850DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.10 -1-47 NOT ON DATABASE A ` LN 6 : r 9 L 03023 2010-09-0114:19 PRECISION EXCAVATING 18457360571» 8452787921 P 2/2 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES :._.PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use rr# %W 2- /-Z--� /a U LYT . Repair Permit issued in IM 5 yews V-��tedte arehed Lif Repair within Boyd's Comem, W. Branch or Groton FWIe Res. ©' ❑ Repair within 20D ft. of a watercourse or DEC- mapped wetland El Joint Review SITE LOCATION OWNER'$ NAME MAILING ADDRESS APPLICANT (;ran r' _.._. thane & ReWonship (i.e., owner, tenant, contractor) r 0 DATE `� -1 b FACILITY TYPE CHD COMPLAINT # PROPOSED INSTALLER • NONE# ADDRESS o � EGISTRAT N/LICENSE# F� MMMI (Include a separate sketch I=ting the house, property lines, all adjacent wells within 200 feet of repalr 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,agres to the conditions stated on this form SIGNATURE TITLE DATE (owner] I, the septic installer, a ee to IY itlons of this permit for the septic system repair SIGNATURE TITLE f - DATE �31 -1D pnt>ttalie� _ etpRS L� with the lglWng oondiliona: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by tine septic system iristaller within 30 days of the repair, In duplkwts showing: a. Owners name, Site Street Name, Town and tax Map number b. Location of Installed components tied to two fixed poire a 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 condf Ions 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 worst is to be bacicfrllgd until authorization to do so has been obtained from the Department. Proposal Approved Proposal Denied in comaliance with Own or; Inst Ter 2010-09-0114:19 PRECISION EXCAVATING 18457360571 >> 8452787921 P 1/2 Precision Excavating Inc. s Rocham►besa Bond r�.�, NY 1052,4 ( "5) 73"571' e>�vodngoti.not FAX TRANSP1ITrAL FORM To: From: Date Sent: :Regarding: No. of Pages: Message: Gene Reed April Leonforte Sept 1, 7010 Tank Repair 2 Gene, Here is a faxed copy of the permit. We will have to wait for mailing to.get the money order. If you have any further questions, don't hesitate to contact us at (845) 736 - 0571. Sincerely, April Leonforte PUTNAM COUNTY HEALTH DEPARTMENT :. DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Ya N® Internal Use Only PERMIT # ❑ ❑ Repair Permit issued in last 5 years ❑ 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 ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS J O APPLICANT Name & Relationship (1.e., owner, tenant, contractor) DATE FACILITY TYPE CHD COMPLAINT # PROPOSED INSTALLER +" _ HONE #S —'� ADDRESS Qb -� C.,r,PEGISTRAT N /LICENSE # LQ`c� Pro sal (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 a d e ent of the repai I, as owner,agreey �eondl!ions stated on this form SIGNATURE (owner) I, the septic installer, SIGNATURE pnstaller) TITLE DATE Is; of this permit for the septic system repair TITLE i a— DATE rroRm aRorovea wim me rommag commons: 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 Alp 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 "rk is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved ❑ Proposal Denied' ❑ Inspector's Signature & Title Date Expiration Date ,Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PC -RP 99ML PCHD; Owner; Installer Rev. 2/07