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02976
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Internal Use Only PERMIT # -
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
Cl 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 TOWN rld-
Y TM #
OWNER'S NAME PHONE #
MAILING ADDRESS NIX 16-5721
APPLICANT
Name & Relationship O.e., owner, tenant, contractor)
DATE -W82 FACILITY TYPE &_514676e- PCHD COMPLAINT # -
PROPOSED INSTALLER L( f/¢n,5' �L�1 fY C- �L e PHONE #
ADDRESS ` &aj�:Avll S , REGISTRATION /LICENSE # 1170
7D
Proposal pnclude a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
e. 4 r c. mitt o f n nn
-��fdC3TEc 'i he Cepartrt ,.n.�rtay�.aau:re- .�:�h�y�;z.ai „- ..,,r..roSal frorr, iicer;sad pt essio. ^.di d::pr r!g- on.2hc.:..
nature and extent of the repair. _ ,o ., / J_ Z/
I, as owner,agree to the conditions stated on this form
SIGNATURE -V,� � � TITLE % ao/� DATE 0
(owner)
I, the septic installer, a ree to comply with the conditions of this permit for the septic system repair
SIGNATURE TITLE 29*91< DATE
(Installer)
Pro MW =gaff d 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.
Approved
INTERNAL USE ONLY
Proposal Denied ❑
�ture Tide Q e Expiration Dad
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is in compliance with applicable codes Yes ❑ Nc(
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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