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HomeMy WebLinkAbout0091DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.19 -1 -18 BOX 2 rlll• ' Al- ,, I r I rlll• a' 7/1 '9 JUL -09 -2007 10:55AM FROM - ENVIRONMENTAL HEALTH 8452787021 1 V I 1 \AIYI VVIJIr 1 1 1 1V11L.1 1 1 vl�l R �,.r�.r i DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use U Lid/ Repair Permit issued in WtSt 5 years ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Repair within 200 ft. of a v4tercourse or DEC - mapped wetland SITE LOCATION /a3o q-A I k I TOWN a it4So- OWNER'S NAME f x'110.9-7 t A f- °Z MAILING ADDRESS /A Zn Q,�e- 3 I 'k t'JA -i-�E APPLICANT C---, e,-(*) . $ ReWonship (i.e., *War. PERMIT # T -732 P- 00011 /{001 F -181 C5 b ❑ Not in Watershed Delegated ❑ Joint Review ,✓;I /TM# 'S • Iq -� -� PHONE # 54N- $M -}-2`r 3 _C,,,- AIQ DATE 0 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER 4E Tee- l " �- PHONE # t( r- ADDRESS PJ ' REGISTRATION /LICENSE # G Z -A t? i 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, II A-(? o Ids t J r4 !-.. c_ (0.7 ,- r04,Jl 3 y-OWS ©f +n��/ r� -"rs In sn�� Ioccif mvl o� s old �•�(o25a �i7s�,11,rtew I, as owner ,agree Conditions d on this form q SIGNATURE TITLE Ab >^ �� DATE '/ e7 (owner) 1, the septic i r, agree to ply with the conditions of this permit for the septic system repair SIG TURE TITLE DATE v. #net er Proposal approved wlti _ he f lowing conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer wlthin 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. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ 4" "). V=..i -1116 O In pectoes Signature $ Title Da Expiration Date Repair proposal is in compliance with applicable codes Yes No CZ COPIES: PCHD; Owner: Installer PC -RP 99ML ' Rev. 2/07 SEP -TECH Inc. P.O. Box 197 — Stormville, New York 12582 845 =221 -977: 845 - 226 -760( IZX4-5 -.; ml - f, I 1—j t W C K V� V 14e- A 1,6 30 .eA :r- &r. b, acknowledge receipt, of thisreport: ',SIGNATURE: Title; Rev: f r �f I�MDIfaiGS ��� i� �0� -�aa v► c� v� �r� �°y �� ±�oar:r h a t t F. r V.; 1 t i } t +f p. lop 'CD A., L � s6rG.l t, i e h a , 1 S+ is ... I�TSPFC'Tf1R s � � TF'T Signature sand Title .. � . . "PP(l'R'r'._RxP P UFL) RV: acknowledge receipt, of thisreport: ',SIGNATURE: Title; Rev: f ,_- "Woty Calls" SEP -TECH Inc. P.O. Box 197 - Stormville, New York 12582 (�1raT�t-AL-2— i�3U � i 311 KT TL f- .50 ► A 1-1 I I'. I� -- 1 1A 00 0 x ib Is • P6 �• lo 3o �s rte, g�<< �1 00 'a.- f 0 �r,, ^,c tvik /Vl f rl�c r�iV►n.L le��� 3 c�- iWeW 845- 221 -9771 845- 226 -7606