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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-PROPOSAL-FOR. SEWAGE 'TREATMENT SYSTEM- REPAIR. - • -. -
YES NO/ _ Intemal Use Only PERmIR # �Z-44
❑ � Repair Permft.lssued in last 5 years ❑ ,/Not, in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Q Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION ''' wRt;Mca 11L TOW TM #
OWNER'S NAME ueA N PHONE # 9 14 , A r ri 43
MAILING ADDRESS VASi 1NdS 04 {wDSon1 ,Ny
APPLICANT
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Name & Relationship p.e., owner, tene
DATE 5-4- 1 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER - .0NW y Se,ue 94t Phi N °L- PHONE #
ADDRESS jig OLO f3� 57- k4016"- REGISTRATION /LICENSE # 1 0/3
Pro sal (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. _
contractor)
I, asap ;ogree to the conditions stated on this form
SIGNATURE M,i-, TITLE DATE ! '` 19 - 11
(owner)
.........1, .the septic .installer,..agre /e-ttoollcomply with the. conditions.,of.thiis permit for the.septic system repair
SIGNATURE �/ TITLE w5�91(c, DATE
(Installer) •
Proposal aooroved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer with_ in 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 1 1
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 backfil until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑ ''�� ��
A�Lb:2i4&1
Ins oes STgnature & Title Difte n tio' �Date
Is in compliance with applicable codes Yes 13 No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Sheet Of_�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL, HEATLH SERVICES
FIELD ACTIVITY REPORT
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Name .and.Title
TYPE OF. FACILITY :
FINDINGS:
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I qfi 9.
ru!yli in Sasenaurf• :...,�i`k /d- 6'� %�',
• �o,se
ears tw be Igo a1
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ulal� tiff Fv ✓n�
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30 ;L3- Xy 1 30
3 .19 57 - /J -,'17 30 2.3
TNCPFC'T0R, TFT
Signature and Title
$F'PQRT RFC'FT E-6 RY•
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
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MAR4 -2011 11:31AM FROM- ENVIRONMENTAL HEALTH 8452787921 T -291 P -001 /001 F -138
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE
All information below must be Nlly completed prior to any scheduling
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PROPOSED CONTRACTOR /INSTALLER
S�t5C441ti, e PHONE ✓# qjl
ADDRESS 1 / 6 -oLO 6N S T P4c4i&k j REGISTRATION /LICENSE # f o1 3
Reason for exploration:
O failure to surface 0 back -up in house 0 find limits of system for repair 0 other (explain below)
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FOR COUN'T'Y USE ONLY
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Ins eotor's Signature & TitIE
Appointment Date, 9 Time
Date
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(914) 737-6548
BENNY SINISCALCHI PAVING, INC.
MASON CONTRACTOR • BLACKTOPPING
SEPTIC TANKS
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(914) 737-6548
BENNY SINISCALCHI PAVING, INC.
MASON CONTRACTOR • BLACKTOPPING
SEPTIC TANKS
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