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00756
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM'REPAIR
fES. NO Internal Use Only
❑ ��Repair /Repair Permit issued in last 5 years �Ze'legated In Watershed
❑ , epair within Boyd's comers, W. Branch or Croton Fails Res.
❑ within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
C
a -e
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
N o _ke�l2s In 5y es
s
PUTNAM COUNTY HEALTH DEPARTMENT D
gti
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
N
PHONE OA7 -
i
PERSON INTERVIEWED FQ 0 U PCHD Complaint #
Name a Bons tp i.e., owner, enan a c.T
DATE % - 0 6 TYPE FACILITY/ eS�/PrGiL�:
PROPOSED INSTALLER HONE �ynI�6
ADDRESS ,� r 0 ( K f' ;° �!` d �` REGISTRATION# 1"L
r1ur:
Pro osal-(include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
I, as owner, or r o ed agent of caner agree to the conditions stated on this form.
SIGNATURE TITLE DATE 4G
Proposal approved with the followine conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of.as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam.
e. Installers' name and number.
3. System repair to be performed in accordance with the abov roposal and conditions.
Proposal- approved
Inspector's Signature & Title l l DATE
COPIES: White (PCHD); Yellow (To BI); Pnappli
t)
PC -RP 99ItII.
X 6' deep
�-3 o -R�%2s to SY e_S
PUTNAM COUNTY HEALTH DEPARTMENT ® .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY O�
SITE LOCATION d SOh
OWNER'S NAME ?W (r-4 — PHONE —
MAILING ADDRESS 02- e etsavl
PERSON INTERVIEWED WAU ?Ion e PCHD Complaint #
ame Relationship (i.e., owner, tenant, etc. /
DATE �- �% -Ota TYPE FACILITY l7e�S��prt l
PROPOSED INSTALLER �S UiDt� i h C PHONE �ei5— n��6 ' 2S1�'
ADDRESS js r7 D Id F4, S2. 4 ,*w// Q REGISTRATION#
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
-� wr
state on this form-.--
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. ' Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be pe ormed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NIL
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Sheet —t of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
N A MF • R) U vt � e- Ted: �(JI
4nngF44> IZ4-- I G �i� P W-.,44
Street Town State Zip
PERSON IN CHARGE
OR TNTFR VTFWFT):
Name and Title
TYPE OF FACILITY: ��- �� ✓`
FINDINGS:
Jf
lG�
A
Signature, and Title
RFP__ORT RF['FTVFT)'RV:
I acknowledge receipt of this report: SIGNATURE:
02/96
R av
Title: