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01211
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use
PERMIT #
V
U ,I V Repair Permit issued in last 5 years U NOYin Watershed
❑ Ire! Repair within Boyd's Comers, W. Branch or Croton Falls Res. 0 Delegated
❑ Repair within 200 ft. of a watercourse or DEC- mapped wetland ti ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
TOWN7�%`c�� c7
L /7? ./,l 9-
Gr_e _ Rb t., T v /Z
# ;Jn.(4')° I
# ��s a 912 _988 /
APPLICANT U i C-1'o R, 1 ) e3 3,U4 _ C.uA/
Name & Relationship (i.e., owner, tenant,', contractor)
DATE FACILITY TYPE / 1uid cLL PCHD COMPLAINT #
PROPOSED INSTALLER P e c L o q, Q Z ,Z,4 t /-j .3 PHONE # /02) /1
ADDRESS C o Al i ,O REGISTRATION /LICENSE #
C 0 iLt -(-9. 0T 19,7.9 A/ /0.r -6
Proposal (include a separate sketch locating the h use, 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. �( r dVC1 ( ' 7. r� 3 `X ,,;t o ' I, /
13 `' `!; t PC- I1 d' ee-4 '-�- %e- -
I, as owner,agr to the conditio s stated on this form
SIGNATURE A_kT I TLE n DATE
..
........ >._........._. ,l,,thP septic installer, -a ee.to comply with the conditions of this.permitlos tl?e septic•system repair. - • • . -
SIGNATURE - TITLE 0CvAIX, DATE �� � ® )
(installer)
Proposal approved with the following conditions: ,
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.
(2/1, No completed work is to be backfillleed until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
App
Signature & Title
is in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Proposal Denied ❑
,Date
codes Yes
,L0
Expir tion Date /
O No CY
Rev. 2/07
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Maker of the Genuine Swiss Army Knife'
INS URA�q Uh w Krvi-,tt a avi
a Title No. PAL23476
Policy No.
SCHEDULE A
ALL that certain plot, piece or parcel of land, situate, lying and being in the
Town of Patterson, County of Putnam and State of New York, being shown
and designated as Lot Nos. 6461, 6462, 6463, 6468, 6469, 6470, 6471,
6472, 6473, 6474, 6475, 6476, and 6477 as shown on a certain map
entitled, "Eighth Map of Putnam Lake, Putnam County,New York ", said map
being filed in the Putnam County Clerk's Office on March 20, 1931 as Map
No. 149G.
For Conveyancing Only
Together with all right, title and interest of,' in and to any streets and roads abutting the above described
premises.
Our policies of title insurance include such buildings and improvements thereon which by law constitute real property,
unless specifically excepted therein. Now is the time to determine whether we have examined all of the property and
easements which you desire to he insured. If there are appurtenant easements to he insured, please request such
insurance. In some cases, our rate manual provides for an additional charge for such insurance.