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Home My WebLink About0083DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.16 -1 -10 BOX 1 "k., �� I11,7. �, 11 Will I' )Irk f'U I NAM UUUN I Y Mt:AL I N UttAh I MtN I DIVISION OFENVIRONMENTAL HEALTH SERVICES PROPOSAL-FOR SEWAGE TREATMENT SYSTgILREPAIR WS . PW / hdamal Use aff -a (97/PAp* Pow& issued In last 5yeas ❑ P1MP*v1MBq1ftCcmer%W Branch orCratan Fdb Res. ❑ T F4eo*idft200&c1a 011111001r[)ISC.roappalWgfaid # U zftn in wow. Eff Delegated ❑ J*d ReWew Ewa, - SITE LOCATION 21 Orcha cd S f --TOWN Pet T Gigs e% q - 1 t rl TM # OWNER'S NAME rl�_n vv-1 a C 'SM PHONE# 52Z &WUNG ADDRESS S 4 j,,e 141C APPLICANT e,;1 I Name "eladonship P.e., owner. tenant, contractor) DATE 16-7 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER,-171 t, fi flSe V //-C- Q�� 3�n e� PHONE # ADDRESS I h"ll,�21,GrP-.I�!�hv7VV REGISTRATION ILICENSE#.9-3 'k 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. 1,=mowner,agree-to-tiW,,Wndillp,ns,%ated-oathis form SIGNATURE TITLE.- DATE (owner) 1, the septic installer, agree to comply with the -COnditions of this. permit for the septic system repair SIGNATURE Z�TITLE re--s DATE Prowsal WArMe-d with the followlF.—nditions: I. Procurement of any Town Permit, if applicable. Z Submission of as built repair sketch by the septic system Installer within 30 days of the repair, In duplicate showing: EL 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. Instants' name and phone number 3 System repair to be PerbMW In accordance with the above proposal and conditions 4. The proposed WrS repair Is considered a best fit design and there is no guararfte to the duration at which the completed SSTS repw vvill "or. 46--biv backded until authorization to do so has been obtained from the Department. COPIES: PCHD; Owner, Installer PC-RP 99ML Rev. 2/07 0 ru I IWAJV► VVVI,4 I Z rlMML.I ri L Fmrm -1 I IYICIV 1 DIVISION OF ENIVIRONMENTAL HEALTH SERVICES THIS IS NOT A REPAIR PERMIT All information below must be ft"I completed prior to any scheduling SITE LOCATION -�-� TOWN - TM k OWNEWS�(NyAME o maS' iv1, i �'"L1 PHONE # C� 7F' � 57 MAILING ADDRESS PROPOSED CONTRAG POWINSTALLEA N ,,, � E PHONE # $r�f� . 7Gr�ro 4l ADD FOSS V P-M lek &a. L-sj /7. C Al q Ar=GIVMTION /LICENSE M '? -3 a2walaoxolorstion: /11 Q fafts to suftes L7 bsv"V in house 0 find Iltnits of sys"in for repair Vother (explain bel*W) EQR_ COUNTY USE ONLY Oki tee: row: /. i , d2Q klymca m"lic Z•d 6869- 6L2-9tPB ijepugl fed eL0 :01 LO iE ��0 �Q►M T BOG . �, .a .. Sheet of'. { " k �y � PUTNAM kCOUNTY DEPARTMENT OF HEALTH h1 :' DIVISION4©F ENVIRONMENTA L HEATER SERVICES: ,sI xkhOz±IEL'D :ACTI'VITI''ItERORT :. t k t :--o''..' "' h �M:,--: P '} 11 d r. iki�wyr �r�,} w h \Its I TPI 3 l �nn-z . ; � e-u / � is y � r T�, /-, � 1 r street ;. T,owri State 11 Zip „�RSQN,I1 CHARGE � _� d`�aiirl�Yct, /'"�E- 'iuTF12UT�F�UUF1� Name and Title j .--I � ITY �YrPEOFC' �,�� r`` t x x �....• 2 t'.. �� -.. . '. -. -.., , .. '.. t - - .. ..: . R ,-t ., 1 i _ ,SNDIN. -' ,.. 's: .: ,� :. .. _ .. .. ft _ d �{ _. ` ;: { �. a .. „ .: .. �r .'. _ .'1.. P ' ' ` .9� /f �_�”' f.'� .k��I R :r t ("it1 ;d t��/ P. [Q C � [ �./ e� �i3b �� { ' 4 ;.: .'. -., - .. ... r. . 7,'- xrSr. -Nt {. Lf� rimed ` IL771 -- % ,r .,�j '.P4 rC J r . �, '� : L:. . 1) - . t sa , I ':. ry / 1. / I C�Vi,w �t �` .; f_t; ear . 1. ✓1 J� ? �r L c/ J. ' Signature:and Title .;.. rmnm m . RF1'FTUFTI RY• . . actcnowledge receipt of this.rep.ort: .. STGNATURE: 2/96 Title; - Rev I =_:- : . o- . I...- -. .