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BOX 17
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES V
.Aft.
YES NO Internal Use Only^ V�
❑ Repair Permit issued in last 5 years VDelegated
of in Watershe
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ Repair within 200 ft. of a watercourse or DEC-mapped wetland El Joint Review
P PP
SITE LOCATION TM # .
'I
OWNER'S NAME & VY iv r/euZilll PHONE # 2 %y- ( 7,f—Y6 (-!j
MAILING ADDRESS T e-1,41 -1)T 'Pa h(eT So N
APPLICANT 0l,wt R ' c' V./,- Uu-
Name & Relationship (i.e., owner, tenarA , contractor)
DATE c FACILITY TYPE Sjn.Glt PCHD COMPLAINT #
PROPOSED INSTALLER0,ey- rnPLc �uy,,Z.,T PHONE # (�rvU -�4ZS-G-06'�'
ADDRESS y y Mple REGISTRATION /LICENSE #
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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. )) J ) J
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE TITLE Owe e - DATE
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 performeZinac rdance wi th the
above proposal and conditionProposal Approved Proposal Denied
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Inspector's Signature & 'tie Da
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev, 8/05
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NJ.
Ea
,, rthCare
All County Division .
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SEPTIC PUMPING • REPAIRS • INSTALLATION
Site Address
Name:
Address: G c rl
City /State:/
Home Phone: Work Phone:
Cross Street:
County: Twp. Map Coord.
Site:
Wk Order:
Billing Address
Name:
Address:
City /State:
Home Phone:
Work Phone:
Zip:
Cell Phone:
Payment: Check #
Credit Card: Amex ❑ Discover ❑ MasterCard ❑ Visa o Other ❑
Card P
Septic Svstem Evaluation & Proposed Action
Exp. Date:
SYSTEM INFO:
CONDITION
RECOMMENDATIONS:
Tank Type: Conc ❑ Metal o Plastic ❑
/Cass
Operating Level U Above Below
Recommend Additive �Yes� No
Tank Size: ��c> Shape:
Drainfield Run Back Yes No
Suggest Aeration Yes CDO
, �,
Depth to Top: to Access: �_
Heavy Sludge Yes
Suggest Outlet Cleaning Yes No
System Saturated Yes o
Suggest Inlet Cleaning Yes �N�7
Drainage System:
Toilet Flushed es No
Suggest Tank Replacement Yes No
Field ❑ Trench o Pits ❑ PD c3
Outlet Baffle Good Bad
Suggest Lid Replacement Yes No
Inlet Baffle Good Ba
Suggest Riser Yes
Suggest Reg Maintenance Yes No
Dousing Tank / Pump: Yes ❑ No r,(
Clogged.lnlet/Outlet , . Yes. No
Next Date:
Comments /Notes )c All---
� / /), ,, e 0�
Customer's Signature.
Driver's Signature „�/ •L / % %�< %/� '�
Customer Disclosure: In the event of payment delinquency, EARTHCARE Is a consumer reporting
company, In accordance with the Fair Debt Reporting and Fair Debt Collection Practices.
Reasonable costs associated with the collection of past due or delinquent accounts are the full
responsibility of the customer.
EARTHCARE, All County Division, will not assume responsibility for damage to driveway or any
off road damage.
CLEANING:
Sept res Lch Sldg Ga
FIELD: SP 3 6 9
Digging /Labor
Cleaned Line INet Outlet
Treatment
Cover/Lid Baffle
Truck Charge
EMERGENCY CHARGE
Billing Address
EarthCare -All County Div.
99 Maple Grange Road
Vernon, NJ 07462
CJ
Sub Total �Q
Tax
Total
XT .�''.
Amt Paid
Great
t 64
311
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PUTNAM COUNTY DEPARTMENT OF HEALTH
---DJ-,VJS-1ON7.O.F E-NVIRONME N;T-A-,L,-HEA-TL
FIELD ACTIVITY REPORT
NAAAR, Ted: A", 191Z) 6 -7 1 —
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Street � Town State Zip
PERSON IN CHARGE
Name and Title
TYPE OF FACILITY: �L?
Ad
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I NSPEA I HAZ
Signature and Title
RFPnRT RFCFTVF-T) BY:
I acknowledge receipt of this report: SiGNATURE.,
02/96