HomeMy WebLinkAbout4865PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ).
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES N-01 Internal Use Only PERMIT # M0�?`Y'
F❑ Repair Permit issued in last 5 years 3 of in Watershed
. ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. r
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 671 NeW4; - SJ ,.}- TOWN La��te- Pee_kSk►,
OWNER'S NAME Yio_AAn1Pv;<.9_ rc-Q- 1�4r�cotcx PHONE #AQ6- ( �03•-(,b?r a
MAILINGADDRESS it ITV k1S3'7
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE /0- a7 -ap f j FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER �eS•�c�ts rnav,��,eM¢�+ A6 Fct -,P NE ## g6 C) - cl;�k hj66
ADDRESS j9' (�� p (� ('- �tQh�� REGISTRATION /LICENSE # I I SO
I ex lo .s o% 19-6 a
Proposal (include a separfate 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
aature and extent of the repair.. , _ A
I, as owner,agree to the conditions stated on this form
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE �a�„ TITLE i DATE
(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.
mTrnu s e.r �u v
wo 1 r-n"PU. V7C VIAL T
Proposal Approved far Proposal Denied ❑
nspector's Signature & Title Date Ex lration ate
,Repair proposal is in compliance with applicable codes Yes 2 No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07