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01232
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES 4C4�
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
'ES NO Internal Use Only
❑ Repair Permit issued in last 5 years ❑ t in Watershed
❑
Vpair Re within Bo d's Comers, W. Branch or Croton Falls Res. I"I Dele ated
Y 9
El Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review
SITE LOCATION ho kM b0 6�- ir9 )expo TM #,-�5 ,63 `Q) J0
OWNER'S NAME c,,r T , �ko� PHONE #
MAILING ADDRESS
APPLICANT
Nam elationship (i.e., owner, tenant, contractor)
DATE `S-'OL FACILITY TYPE 110A& PCHD COMPLAINT #
PROPOSED INSTALLER -Je' e- PHONE #
ADDRESS 6�,,,t6rn ra. f 9 v %+ L REGISTRATION /LICENSE #
J1rdY
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or rec&tered architect.
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I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE TITLE%j>J���r
Proposal aped with followin 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
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditions.
Proposal Approved _/ Proposal Denied
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Inspector's Sig�nature'& Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
DATE T'O�
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