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HomeMy WebLinkAbout0233DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4.19 -1 -14 BOX 3 y , 1jii 00042 y PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Q YES Internal Use Only PERMIT # ❑ cM Repair Permit issued in last 5 years ❑ Not in Watershed ❑ �. Repair within Boyd's Comers, W. Branch or Croton Falls Res. 0 Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review .SITE LOCATION,560YJAVP �����6Gd�T 'TfOWnN/ ' © TM # Q' -14 >` OWNER'S NAME A97 �I� 41 ,4 PHONE # 5%S MAILING ADDRESS: 6 ! J7 c- % i9 L 4 .APPLICANT "A0 CDC " Name & Relationship Q.e., owner, tenant, contractor) DATE FACILITY TYPE S �CHD COMPLAINT # PROPOSED INSTALLER PHONE # (5 `(S� -2 z - z 2!-10 ADDRESS ,j/OJU, L � o�, ae ,-J %I REGISTRATION /LICENSE # ,10D • lines, all adjacent wells within 200 Pro sal (include a separaie'sketch locating the house, property j 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 conditions stated on this form Q SIGNATURE TITLE ((� ✓�i.t/' DATE (owner) I, the septic installer, agr o comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE V (Installer) ProRl, anoroved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as,"Wilt .reOair 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. / INTERNAL USE ONLY Pr sal Approv Proposal Denied ❑ 5[3ho A / Ik Ins or's gnatu xpi re & Title Date Er Date epair proposal is in compliance with applicable codes Yes O No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 1r {�� 1 C�-- S��c LEACHING DRY WELL 6 DL4. K.O.'s H -20. Loading ►- IM "l Route 9 • Cold Spring, New York 10516 845 - 265 -3265 a o ® ®� o o a QpQS �i IN= ® o c a D tl12 192 ® m C"J Z=m O 48. d Cf ®9 Y�rh. G ca== O . . ji pi�'�Yj p Cppi F+Sr'Y ®3 Ct 'P�+' O O j4 �t 48• ► ►- IM "l Route 9 • Cold Spring, New York 10516 845 - 265 -3265 i. 6PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR yu Xo Intemal Use Only PERMIT # ❑ d& Repair Permit issued in last 5 yews ❑ Not in Watershed ❑ fil Repair within Boyd's comers, W. Branch or Croton Fam Res. Delegated ❑ fil Repair Wmir, 200 ft. of a watercourse or DEC-mapped wetland ❑ Joint Review SITE LOCATION ,5f C! /A/ OW,,;NEFi'S NAME MAILING ADDRESS APPLICANT , Vh"-4'65ZOT- TOWN 5- 11V TM# A4+9--,A PHONE 7, Name & ReWonsNp (.e., owner, tenant, owbactor) DATE FACILITY TYPE HD COMPLAINT # PROPOSED INSTALLER PHONE# ADDRESS REGISTRATION /LICENSE # PmRaW (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. 14cA C' 1, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) 1, the septic installer, agre",comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE L2, l I D (Installer) ft. B=0W ARRmW 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 Installet! components *4 to two fixed points G System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in acoorclance with the above proposal and conditions 4.- -ThWordposed SSTS repair-Is. cqnsidered east fit design gnA.tfwe i ,",no guarantee,t4 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 PrgpqsW Appr Proposal Denied ❑ Al in"oes ni nature& Tide Date ► Expilion Date Repair proposal is in com Yes with applicable codes 13 No EY PCHD; Owner, installer PC-RP 99ML Rev. 2/07 I