HomeMy WebLinkAbout4859PUTNAM COUNTY HEALTH DEPARTMENT
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES _-
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
'ES NVI Internal Use Only PERMIT # � p =F6' /J
❑ ® Repair Permit issued in last 5 years t I atershed
❑ 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 TOWN pq TM #
OWNER'S NAME F ���SSc� i �! 0��� PHONE # A9s -t'�3 c'.,4ni1�
MAILING ADDRESS Ct F)r9cn el eL-4-, � X P v4,, .wry t icy 1 ho „ L-04 f at:77q
APPLICANT Me % y 1,�r o - () w rN r
Name & Relationship (i.e., owner, tenant, contractor)
DATE ��I - Aol I FACILITY TYPE ; ,cP�CHD COMPLAINT #
PROPOSED INSTALLER ?VSAQmkS (YYanac,Neme_r -c,3Qh Pct<c �tPHONE # - �{ - 6/1,6 X I % D
ADDRESS nl 9 Mn.nlo 0r.,, , Q Qln REGISTRATION /LICENSE # I SO
VQCK1 on, IVY 07 ct 6�
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
mature and extent Af the repair. - - lei
I, as owner,agree to the con 'tions to on this form
SIGNATUR ITLE DATE sf i
(owner)
I, the septic installer, agree to comply with the conditions of is permit for the septic system repair
SIGNATURE TITLE DATE - at w a0I I
(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 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.
in! CMNAL UJC URLT
Proposal Approved Proposal Denied 0
1112- 1?,//
Inspector's Signature & Title Datd Expiration Date
Repair proposal is in compliance with applicable codes Yes 2-. No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
a RMS Company
All County Division
99 Maple Grange Rd
Vernon, NJ 07462
1- 800 -428 -6166
Job Name
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Customer # 11-1 31215y
Address
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City pUAVI� VQJI
State
Zip
Block 231
IA-'I- '-)'6
Lot
Home Phone
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Date
Job Description
EC 113606 -2