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Home My WebLink About48571 airy fo-t r `rXvcc PUTNAM COUNTY HEALTH, DEPARTMENT 4 J DIVISION OF ENVIRONMENTAL EALTH SERVICES � i� CJ PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR XR NQ Internal Use Only PERMIT # -0 3 -0 0 Repair Permit issued in last 5 years of in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated 11 V Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review _! W""7 Wr ' Name & Relationship (i.e., owner, tenbint, contractor) r k—/ - DATE 4 N)0 FACILITY TYPE '$?S PCHD COMPLAINT # PROPOSED INS ALL R -Torn . hI1)<;;- Qp ®t y&, PHONE #CJ 14 4J — ADDRESS REGISTRATION /LICENSE # ...; D�. 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 and extent of the repair. , CA I, as owner,agree to the conditions stated on this form SIGNATURE TITLE 0 W IJ I~ 1Z DATE (owner) R a- P c.LEr4 I, the septic installer, to comply with the onditions of this permit for the septic system repair SIGNATURE TITLE a; yin DATE (Installer) 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 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. INTERNAL. USE ONLY Proposal Approved Q "Proposal Denied ❑ zzz Inspector's Signature & Title D e Expiration Drate ,Repair proposal is in compliance with applicable codes Yes (a No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 -<',z � IF wed MEMORY TRAN SM IS S I ON REPORT TIME APR -15 -2011 03:00PM TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 644 DATE : APR -15 02:59PM TO . 85262560 DOCUMENT PAGES 001 START TIME APR -15 02:59PM END TIME : APR -15 03:OOPM SENT PAGES . 001 STATUS. : OK FILE NUMBER 644 * ** SUCCESSFUL TX NOT ICE * ** PUTNA'M CC>UNTY HEALTH DEPARTMENT G o E) VIS10N OF EN\/IRONMENTAL. HEALTH SERVICES 0 PROPOSAL PdR SEWAQE TREATMENT SYSTEM REPAIR tntarnal Use Onl PBRMfT • -Q Rapalr Permit issued In Iasi 5 yeCVe of In Watershed O / Rapalr within Ooya's Corner -, w. Branch cr Croton Felts Res. �OelegatBd M _ [� Repeir witnln 200 tt .r a wetervo.•rma 4 pHC - mapped wetlrn.d 1] Joint IRa•riaw, SITE LOCATION OWN H TM A OWNER'S NAME L P ONE p MAILING AMMRESS Je-TZ tJama 6 Relationship Q.e.. owner, tenRaM. contractor) • `� MATE FACILITY TYPE �P -V PCHM COMPLAINT 0 PROPOSED -IN ^S ALL R - T-Aeyn d? J la4dhc r PHONE #C3 I�4 sir -F -CO x,-1. &AA= REGISTFttATION /LICENSE 4f-4=6- ) QS2Ejt Proposal pno {udp a separate stcatch locating fire house, property tines, all adJaoertt walls within 200 feat Of rapalr and ttta location of axis ting and proposed ayaiarn) NOTE: The Mapartment may raqulre submittal of proposal from licensed profassionat depending on the nature and extent of the repair. _ _ _ _ _ , __ , _ _ •, .- �,., , r, 1, as owner.agme to the condKionsasytetted cn this form SIGNATURE MATEj�2 (owner) Wp ifL L.-Y, LI A H p 4r-- C- W-- ./ 1, the naptic installer, a to comply with'thee tionditicns of this permit for the nap�tic system repair SIGNATURE - ^ TITLE h�i?� �•�� %r° —'- MATE (Ins[allar) , t 1 . Procurement of any Town Parmlt, if aPplicable. 2. Submission of as bunt repair sketch by the septic system Installer within 3O days of the repair. In duplicate ahowing_ a. Owners name. Site Street W—. Town and Tax Map number b. Location of Installed - mponerrta tlad tc twc fixed points c. System description (a.g.. 1230 gal- Concrmte septic tank. etc.) d. Installers' rtarr•o and phone number 3. System repair to ba performed in accordance with the abcva proposal and conditions 4. The proposed SSTS repair is considered at bast fit design and there is no guarantee to the duration at which the completed SSTS repair will function- s. No compiatad work is to be baokfillad until authorization to do so has bean obtained from the Oapartnient INTERNteL USE.ONLY • Proposal Approved Proposal Menled Q In ctor's Signature a. Title o e ration EYate Re air PrO nml Is in Com lianca with a livable -odes Yes No O COPIES: PCHI:>; Owner; Installer � PC -RP 99ML Ray. 2/07