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01071
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01071
SITE LOCATION /
OWNER'S NAME C
MAILING ADDRESS
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PUTNAM COUNTY HEALTH DEPARTMENT .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
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PHONE ,r JC ,:?7 ?- ,:;2�
PERSON INTERVIEWED PCHD Complaint #
Nanle,,U RelationsEip (i.e., owner, tenant, etc.
DATE t� W E
PROPOSED INSTALLER
ADDRESS
TYPE FACILITY Ras.
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REGISTRATION# ?2
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.
_... _.,. _........... _..._.._.. .._._....,......_ -.. _...._............... _. .......... .
I, as owner, o, repo d agent o o p.. er agree to the conditions stated on this form. g�
SIGNATURE TITLE� DATE
Proposal approved with Zekilowing 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 7rfb rme d in accordance with the above proposal and conditions.
Proposal approved
zit'
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
Street Town
State Zip
'PERSON-IN CHARGE
OR TNTF-IRVTF.
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
Internal -Uso Onl
❑ epair Permit issued in last 5 years VDelegated
of in Watershed
El ,Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ Q Repair within 200 ft of a watercourse or DEC - mapped wetland ❑ Joint Review
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
iuc) Re PG t Rs t2S
PN1 Cp
SITE LOCATIOT
OWNER'S NAN
MAILING ADD]
PUTNAM COUNTY HEALTH DEPARTMENT
DMSION OF ENVIRONMENTAL HEALTH SERVICES
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PHONE kys .Z?7k %
PERSON INTERVIEWED go r✓r PCHD Complaint #
am elatlonstup�t.e., owner, tenant, etc.
DATE F5I oI¢% 6 TYPE FACILITY R�fS
PROPOSED INSTALLERT�g�ut7��•tr�, PHONE,re279.5�cPQ�
ADDRESS
Proposal (include sketch locating all adjacent wells):
REGISTRATION #33
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 reported agent ofjq�amer agree to the conditions stated on this form.
i
SIGNATURE TITLE DATE
Proposal roved &ellgwing c
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 comers).
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 performed in accordance with the above proposal and conditions.
Proposalapproved
Inspector's Signature & Title
COPIES: White (PCID); Yellow (Town BO; Pink (applicant)
PC -RP 99ML
DATE
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August 2006
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14 Brandon Rd
Patterson NY
Tax map# 25.49 -1 -25
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EXCAVATING CONTRACTORS
_ 845- 279 -8809
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