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HomeMy WebLinkAbout0596DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -61 BOX 7 How, , .: . How, , PUTNAM COUNTY HEALTH DEPARTMENT '� " Z 11 I Z ,r' t DIVISION OF ENVIRONMENTAL HEALTH SERVICES p PROPOSAL FOR SEWAGE TREATMENT SYSTEM REP YES NQ./ Internal Use Only PERMIT # 0 Repair Permit issued in last 5 years 1:1 of in Watershed El Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME�� MAILING ADDRESS APPLICANT TOWN TM Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER PHONE # ADDRESS 1/ y 10 REGISTRATION /LICENSE # ©,5+� 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 , naturp anti pxtpnt of the renair t I, as owner,agre to the co/n�dition stated on th' form SIGNATURE /l ITLE DATE (owner) I, the septic aller, agree to comply with the conditions of this permit for the septic system repair SIGNATURE �� TITLE UJ0, 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. INTERNAL USE ONLY Proposal Approved re & Proposal Denied is in compliance with aoDlicable codes COPIES: PCHD; Owner; Installer PC -RP 99ML X Dat6 EXDI ation Yes V No O Rev. 2/07 —/—O ci P, eTl ✓%N/C FAR` To retemr7- cTol N Si ae�`lowfcl, f 61 / 1 e,?Sov Ivy /7S °1�UILj- rA d 2 m To 9,0 C GNT/? fi e —IOf- S'Tv6Ar �eS 1- ;sc�*/0Sa To lq,sli 7 To ovTleT = / ?, To ovrlel-= )VV" I fvoTcs" po 0 p / lo1v FXa to 7,*61k R)Se,e 3/1 Deep GR.sr 1 O."lv y /. TO T4A)I -e S,O,'3- oo7- To dox