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25.79 -1 -13
BOX 13
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01361
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH. SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAII
YES NO Internal Use Only
❑ Repair Permit issued in last 5 years
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ p air within 200 ft. of a watercourse or DEC - mapped wetlam
SITE LOCATION
OWNER'S NAME UC /
MAILING ADDRESS
APPLICANT
ame & Relationship (i.e., owner, ten nt, contractor)
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❑ of in Watershed
Delegated .
❑ Joint Review
-)DM 5. -I -I!�>
PHONE #
DATE / / FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER 7ld l� � JlZ (/ 4f ���, PHONE # Ixi) 7% mf
U // REGISTRATION /LICENSE # 1
ADDRESS � �L'�/ 777
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 registered architect.�����
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I, as owner, or report nt of owner agree to the conditions stated on this form
SIGNATURE TITLE
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
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
� //347,6
Inspector's Signature r& Title Datef
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
DATE ��
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