HomeMy WebLinkAbout4863SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
PUTNAM COUNTY HEALTH DEPARTMENT
IVISION OF ENVIRONMENTAL HEALTH SERVICES
TM
Internal Use
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res
air within 200 ft. of a watercourse or DEC - mapped wetland
Ll �� TOWN
C
PERMIT* T-N-
U Aot in Watershed
6 Delegated
❑ Joint Review
TM # 7
PHONE # / 7Y
Nai e & Relationship (i.e., owner, tenant, contractor)
DATE f-ACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER .y �.�F i - C PHONE # 141 / 4 " G
ADDRESS f J%
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, as owner,agree to the co i:ion this form
/ �'
SIGNATURE �`'� TITLE DATE 7
(owner)
I, the septic installer, agree . co the conditions of this permit for the septic system .repair ,
SIGNATURE TITLE DATE
(installer)
Proposal am3roved 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.
Proposal Approved
Signature & Title
is in comaliance with
INTERNAL USE ONLY
Proposal Denied
codes
Fol
7 30 0
Date
Yes
Expiration Date
❑ No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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