HomeMy WebLinkAbout4860PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES NO , Internal Use Only PERMIT # Z -� JU/ / 1
❑ Repair Permit issued in last 5 years of in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res;, Ld Delegated
❑ Repair within 2W ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 60{ iA.kG D We, TOWN J��IN1 �t�)� ,. TM # �j3d(p!p °o�- 7o
OWNER'S NAME &Wa.;4) WWO eJ Qea,1 PHONE#
MAILING ADDRESS 6,2 tat h e, iD C%IJa- RJrW W% ti l l
APPLICANT
Name & Relationship (i.e., owner,
DATE 16- 15 — FACILITY TYPE Ptei %dv-A�,aL PCHD COMPLAINT #
PROPOSED INSTALLER "�a 5'
R ��('7.Q �e�a WO v►�c,c�►u.1� L ` PHONE # 17/% ,37T p y 00
ADDRESS 2&1 6 wide.4 0 Ade_)�ak *R 1-4v REGISTRATION /LICENSE #
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 >J e-- c, ('e.. „v► l-!, r to t 4 � C.41
I, as owner "thhee stated on th is form .
SIGNATUR TITLE O W N e Ct DATE —19 - .Z c I I
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE ` TITLE 0W Pa?- DATE
(Installer)
Proposal aooroved 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 sho":
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.
S. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑.
n pector's Signature & Tiddl .Datd ExP ration Date
- • . . ,,
Repair proposal is in with applicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
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