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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES.._: n Internal Use Only PERmiT-# 1�" j3 9 -o?
❑ Repair Permit issued in last 5 years ❑ ,,olQot in Watershed
❑ LK Repair within Boyd's Comers, W. Branch or Croton Falls Res. 0 Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION TOWN %�vT,v e/ TM # ®. (-W
OWNER'S NAME B PHONE#
MAILING ADDRESS 3 7SJ4cv7ZE, 2c-:,a-
APPLICANT (''
Name & Relationship (i.e., owner, tenant, contractor)
DATE �o�� y/0 FACILITY TYPE lZq-`S. PCHD COMPLAINT #
PROPOSED INSTALLER ®mss �T�d� c�"� PHONE #
O- P4 ase-4,e ^14 �
ADDRESS Ai ¢a ye U,.. -.� ® � ?,Q REGISTRATION /LICENSE .# �1 443�
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 oo
SIGNATURE TITLE „yg DATE 6`��// ®�
(owner)
- - -- . I, the septic instal r, agree to comply with the conditions of this.permit for the septic system. repair
SIGNATUR TITLE _rm DATE a1X y 07
(installer) -
Proposal approved with the following 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 backfil!pd until authorization to do so has been obtained from the Department.
Proposal Approved
pector's
is in com
INTERNAL USE ONLY
Proposal Denied
with applicable codes
A
D to
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Yes
Expiration
❑ No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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