HomeMy WebLinkAbout4862PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICE;
EWAGE TREAT
Internal Use On
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
I]� Repair within 200 ft. of a watercourse or DEC - mapped wetland
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
PERMIT #
❑
Not in Watershed
0
Delegated
O
Joint Review
TM #
'
PHONE #
e2-p
r1 C
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT#
PROPOSED INS ALLER L "r >nS �j� /�' PHONE #
ADDRESS j,(ar j. 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. n Al / / . //
I, as owner,agree to the conditions stated on this form
SIGNATURE: =z�=� 1 TITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE. ����,• -y TITLE �'� "� / DATE C, v`� O
(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 backfill90 until authorization to do so has been obtained from the Department.
Proposal Approved L'J
` nspector's Signature & Title
Repair Dr000sal is in compliance with i
COPIES: PCHD; Owner; Installer
PC -RP 99ML
INTERNAL USE ONLY
Proposal Denied
codes
0
aZ-
Dat
, Yes
Expiration Date
❑ No
Rev. 2/07