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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES V
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Internal Use Oniv PERMIT # /T -dc ) c ) —
❑ Q/�e 'r Permit issued in last 5 years �❑l Not in Watershed
11, ®' epair within Boyd's Comers, W. Branch or Croton Falls Res. �h' Delegated
❑. Repair within 200 ft. of a watercourse or DEC - mapped wetland (❑ Joint Review /
SITE LOCATION l OML TOWN Pc ti o• TM # �j tp
OWNER'S NAME 2d�,�r� LC M8 PHONE #
MAILING ADDRESS -70L L ^�5�' Alrc,4,� to, #4450tH J lt/ I LS' -43 .
APPLICANT &04 er+ C-WA o O V4 h Q V
Name & Relationship (i.e., owner, tenant, contractor)
DATE G FACILITY /TYPE Q$ e n PCHD COMPLAINT #
PROPOSED INSTALLER (�� _ PHONE #
ADDRESS 37 6: 1111 -1 REGISTRATION /LICENSE #
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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
I, as owner,agree to the conditions stated on this form
SIGNATURE ��� C� TITLE Q wi, DATE
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
I
SIGNATURE 4el;e TITLE f�� DATE
(installer)
Proposal app ed with th ollowing conditions:
1. 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.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Pro osal Approved all- Proposal Denied ❑
Inspector's SiOndrure & Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes 0/ No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
_ Sheet 1 of 1
S T
Putnam County Department of Health
Division of Environmental Health Services
Field Activity Report
Name: B Cuomo Telephone:
Address: 706 East Branch Rd Patterson NY 12563
Street Town State Zip
Person in Charge or Interviewed: Date: 11/29/11
Name and Title
Findings: R- 253 -11, The septic repair was done as per permit. Replaced 4 D- boxes.
Inspector: �., � G iv A Telephone:
Signatur, d Title
Report Received by:
I acknowledge receipt of this report: Signature:
Title:
Field Activity Report: cw Date:
555-
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