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02872
a PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
. .... _ _ _.. ..__PJR0P`fS -A -FOIE. SEt'!'sAGE 1r*RU.T:!aE
YES NO Internal Use Only PERMIT # \ - \ " U`
❑ / Repair Permit issued in last 5 years El ^t in Watershed
❑ . % Repair within Boyd's Comers, W. Branch or Croton Falls Res. � Delegated
El Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION TOWN b7fv,--, UA TM # 62 - L3 _ I " 1S
OWNER'S NAME Af'4N F_ MAIL & .E5 AS, It 2 PHONE #
MAILING ADDRESS 7 Lpkll' L/1 6k/ OA PvTadan. uNa� -,
APPLICANT ^ 2 j 5 A)C,
Name & Relationship (i.e., owner, tenant co tra r)
DATE t; FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER 1 ' 2 Z Oft isna s -t y c. PHONE # 01/4 73q 34L-
ADDRESS 71DOy UAOOD iZO G® tit &iv.O r Moovor REGISTRATION /LICENSE # (08(o
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 a to the d' s stated on this form
r
SIGNATURE` TITLE . C�ctN' DATE / d
(owner).
i, ine septic instaiier; agree to com'piy'with'the conditions of this permit Yor the septic system repair
SIGNATURE TITLE .v DATE -7J5J,0 <
(installer)
Proposal a rov - the Ilowin conditions: s
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 U5E ONLY
Proposal Approved " Proposal Denied ❑
`b . 7 7 0 0
nspector's Signature & Title Dat6 Expi tion Date
.Repair proposal is in compliance with applicable codes Yes O No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Q
YES NO Internal Use Only PERMIT # \ - \ " U`
❑ / Repair Permit issued in last 5 years El ^t in Watershed
❑ . % Repair within Boyd's Comers, W. Branch or Croton Falls Res. � Delegated
El Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION TOWN b7fv,--, UA TM # 62 - L3 _ I " 1S
OWNER'S NAME Af'4N F_ MAIL & .E5 AS, It 2 PHONE #
MAILING ADDRESS 7 Lpkll' L/1 6k/ OA PvTadan. uNa� -,
APPLICANT ^ 2 j 5 A)C,
Name & Relationship (i.e., owner, tenant co tra r)
DATE t; FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER 1 ' 2 Z Oft isna s -t y c. PHONE # 01/4 73q 34L-
ADDRESS 71DOy UAOOD iZO G® tit &iv.O r Moovor REGISTRATION /LICENSE # (08(o
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 a to the d' s stated on this form
r
SIGNATURE` TITLE . C�ctN' DATE / d
(owner).
i, ine septic instaiier; agree to com'piy'with'the conditions of this permit Yor the septic system repair
SIGNATURE TITLE .v DATE -7J5J,0 <
(installer)
Proposal a rov - the Ilowin conditions: s
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 U5E ONLY
Proposal Approved " Proposal Denied ❑
`b . 7 7 0 0
nspector's Signature & Title Dat6 Expi tion Date
.Repair proposal is in compliance with applicable codes Yes O No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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LIC.# WC-4149-H91 PIZZELLA BROTHERS, INC.
LIC.#PC-192
SCALE: APPROVED BY: DRAWN BY:
REVISED:
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALT>EI
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FIELD ACTIVITY REPORT
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Street' Town State Zip
PERSON. IN CHARGE 1
Name and Title
TYPE OF FACILITY
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Signature and Title
-REPORT RECEIVED Ry:
I acknowledge receipt of this report: SIGNATURE:
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-REPORT RECEIVED Ry:
I acknowledge receipt of this report: SIGNATURE:
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