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BOX 19
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02208
PUTNAM COUNTY HEALTH DEPARTMENT
DJVISION OF ENVIRONMENTAL HEALTH SERVI
YES NO Internal Use Only PERMIT #
❑ Repair Permit issued in last 5 years
❑ . Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑
SITE LOCATION 3� - �� /�P,� lufA1(TOWN r� TM #
4
OWNER'S NAME S�. ,J, OZ dtC PHONE #
MAILING ADDRESS Stfiletorf
APPLICANT'
11
plot in Watershed
Delegated
Joint Review
f/y `f'I - c-'au
Name & Relationship (i.e., owner, tenan contracto
DATE t; t 0. A02 FACIL17 TYPE 1poloe r,C►C__ PCHD iCOMPLAINT #
PROPOSED INSTALLE `vm�4E' p4 PHONE # � 5 CPjv
ADDRESS ��J c/� T4 — 1 /J 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
SIGNATUR
(owner) (
I... .. _ _ � -. I; the - septic
i this form
TITL
Iva to comply wit t. onditions of this p it for the septic
SIGNATURE . a / TITLE D)
(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 rep
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points f
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
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
nspector's Signature & Itle ' Da e
is in compliance with apDlicable codes Yes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
.> eee— seo-ri C,
n repair •' °
dot J0 i1b 3
r, in duplicate showing:
iuration at which the
le Department.
Expiration Date
No O
Rev. 2/07
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SURVEYED & PREPARED BY /VE6'Y/ r0R .
.StJ.illNE'Y ASSOC 1RTES
ENGINEERS & . SURVEYORS SCf�L .�: �Na /00
956 ;KATONAH AVE.
KATONAH, NEW YORK
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' PUTNAM' COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH `SERVItCE$ ��a;•
A .A R. C ®� T T NT T M ���(\
.'' dO'GSAL F,OI� SEWAGE :tl REk MEYV-F SYS FEfR`Y. R.EP�AYV...a..
-
i , -Y;N InterUse l
On .PERMIT#
nal =
RepairrPermit issued in last`5 years " rot in •WatefBhed
' ❑ " i Repair within ' di Comers W Branch or Croton Falls Res.,,— '' ' Delegated
` ❑ : • ❑' {�. `Repair,within,200 ft of a wiitercoorse or DEC = mapped. wetland Joint RevieVll
SITE LOCATION = /r 7 XXWV TOWN � 1 r TM #'
OWNER'S NAME .:'fie PHONE #. S, f".y�!
MAILING ADDRESS t
l t l e> t1• P , s rrtit'.ii ;`.'1%r�l �1",. I J Ul
APPLICANT i '..: �!"'• - -?` ' rt; CiiF -•.G -; f ,�
+ Name & Refatfonship, e:, owner, tenan c ntracto) . c`
DATE /'joz /, �r ="Vvc) AGILITY TYPE .mod /0ev +,." PCHD COMPLAINT #
PROPOSED INSTALLER, PHONE ".79 1
_ _
r~
M- -
ADDRESS ,-y : REG STRATIOLICENSE # i� 1
an,
Proposal (include a separate sketch locating the house, pbperty lines, ail adjacent wells within 200
feet of repair andahe location of existing anti proposetl s�tstem) ��
.NOTE: The :DepArtMent may requireaulimittal of proposal from licensed p ofessid" depending on the'
(`
nature and extent of the repair f
1F1#�
'R��.,1 � i.F( -i�� ! 1. - 1 } � T '! •- � - .�A� '` L.+�• - .. _ _ _ _
,
d:
I, as owneriagree toahe conditions ted orr is form
SIGNATUREc"' r 1`ITLE�,9" -s DATE
(owner) • -
-• i
-the
septic trtsi�lier, a r e t® comply. with thpK ditioi is qfi tfiis peI'm, f :'sept c yytem repair - - -
. ;SIGNATURE t', n f i 'TITLE°�r DATE �
(instellerj: r
Proposal apRroved with the':following conditions:
y� 1 Procurement,of any Town Permit,' if applicable.
Submission of as, buiit repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a Owner's name; Site Sireet Name, Town and Tax Map number
b. Location of rnstalled components Ued to two-&& Dints ' : µ
C., System description (e:g ,1250 gaC 'Concrete septicaank, etc )
d: Installers' name and phone number. .
f V 3. } System repair' to be performed ,.in accordance. with the above proposal and conditions
.4. The ro osed SSTS re air is:considered a besffrt design there is no uarantee to the duration at which the
P P P; 9 9
completed SSTS repair will function.
5:' No completed.worR is to,be backfilled until"authonzaition to doso,has been obtained from the Department.
ti INTERHAL�QSE ONLY...
v , Proposal" Approved , i rF Proposal Denied ❑ t rte' } ;
ti�s/ r S i � ''. • ?f17 t � -''
y�„yres++ '?,i l vf�� +�:' ,� • 34 �,,-.`' rte,.. i" ir+.�.r .c" �XLi'i
�u
f nspectol s Signa re & �tle Date Explration�Date
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i s M^rrt�t �Ctni�,1. +r y, ... ..f!" �j�„ •,
Re air ro osal.)s;in'corfi ,a inCeY;wlttt.a Ilcable codes.. - :Yes .:.: L
- Noy❑ ,
COPIES:; ^`PCHb�`i�iirrer, Installer
PC -RP 99ML. f ReV. 2107 ,r# ,,.•., -
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