Loading...
HomeMy WebLinkAbout0610DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -17 BOX 7 00610 -�� I .� Ir me L ` it r . 00610 /V/ PUTNAM COUNTY HEALTH DEPARTMENT 0!4 DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES N01z Internal Use Only PERMfr # ❑ 1.Z1 Repair Permit issued in last 5 years ❑,Not in,Watershed ❑ 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' �a - J _ s: TOWN .19, =,q (_ -- TM # OWNER'S NAME , PHONE # Q MAILING ADDRESS %., l A&.94',m as A'�'4. !;-- Gy�'� t T�SDi'i /V /�•9 G � APPLICANT'` Name & Rel nship (i.e., o )r, tenant, contractor) DATE 2, FACILITY TYPE `S . PCHD COMPLAINT # car PROPOSED INSTALLER PHONE #_ �,�71�% ADDRESS �'_EGISTRATION /LICENSE # I1C4 Proposal (include a se 48,te 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 nah ira and axtant of tha ranair I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) I, the septic installer, agree �to- comply with a conditions of this permit for the septic system repair SIGNATURE TITLE DATE ' (installer) 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 36 days of the repair, In duplicate showirp: 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 ❑ z ;z1 �a In' oector's Sianature & Title Ex6irationDate is in comDliance with aDplicable codes Yes COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2107 To: Page 2 of 2 2012-09-2109:24:35 EDT 19144623759 From: Baker Properties PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR XM h2 Internal Use Only PERMIT ltr ❑ ❑ Repair Permit issued In last 5 years ❑ Not in Watershed ❑ U Repair within Boyd's Comers, W. Branch or Croton Falls Res. 0 Delegated ❑ ❑ Repair within 200 ft. or a watercourse or DEC-mapped wetland ❑ Joint Review SITE LOCATION 1 fncr(ho+rw',;' 3 t2 . TOWN R � Y1 TM It OWNER'S NAME PHONE # o?D -_ool`AO \b MAILING ADDRESS APPLICANT Name & Relationship (i.e., owner, tenant, eonftdor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER PHONE # ADDRESS REGISTRATION /LICENSE # Pro al (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. I, as owner,agr to the conditions stated on this form /r- SIGNATURE, TITLE DATE (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE (Installer) Proposal aoixoved with the following conditions: 1. Procurement of any Town Permit, it applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair. In duplicate showirt. a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. Systern description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed In acoordance 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 ❑ Inspector's Signature & Title Date Expiration Date Repair proposal is in corn liance with applicable codes Yes O No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2107 �2d to � m "o � N O C � mN EXCAVATING CONTRACTORS 20 Ivy Hill Rd., Brewster, NY 10509 (845) 279 -8809