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BOX 20
02373
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02373
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_._ �...._. _ .._._..... P GPO —SAL FOR - SEWAGE. TR.EATM
YES NJ Internal Use Only PERMIT #
❑ ZD Repair Permit issued in last 5 years U Not in Watershed
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION ?k6%A -vS P-0 TOWN v w,o,�v� /lr TM # IZJ
OWNER'S NAME +l&e .:-V-t ANCkr,,,, PHONE #
MAILING ADDRESS SiE ire AS CIAO
APPLICANT
Name & Relationship (i.e., owner, tenant,rcon dtor-%
DATE ) 7 ;W/c FACILITY TYPE i9,9 S PCHD COMPLAINT #
PROPOSED IN TALLER i/;�rJw ��.� 1 c PHONE # u %3- fL9 -o�ac S/
ADDRESS ��i�/.o -� �� . /,�j�.»� G� REGISTRATION /LICENSE # /0/'7
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 }
Y r S 1/d It �. dDU (� 4�0 p- �.✓�LY2 7546-1,
I, as owner,agree to the conditions stated on this form
SIGNATURE U/ TITLE c u c- oL, DATE 3-u ,.,t Z
(owner)
" J I;- ttie'septic'in taller, agree to comply with the °conditions of this'petmit fd-r the septic system - irepai "
SIGNATURE % TITLE DATE G /% z' /G
(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 backfilled until authorization to do so has been obtained from the Department.
.1 1l4il7;«Ti *41eiL M
Proposal Approved Proposal Denied ❑
nspector's Signature & Title Dat6 Expir tion ate
,Repair proposal is in compliance with applicable codes Yes O No
COPIES: PCHD; Ow
.rier; Installer
PC -RP 99ML
Rev. 2/07
ARROW EXCAVATING, INC.
15 AVALON COURT
HOPEWELL JCT., NY 12533
JOB
SHEET NO. OF
CALCULATED BY DATE
CHECKED BY DATE
snei c
1
JOB . STC A1P- Ap 0 N(tjf- RAk K19 i
ARROW EXCAVATING, INC. SHEET NO.O pgpU^C "!' ST. OF-
15 ELL JCT.,-NY COURT ,�QdG� Fxe,_ X C
HOPEWELL JCT.,.NY 12533 CALCULATED DATE tU
CHECKED BY DATE