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02996
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02996
1. PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_. _..._ _
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
- - �::
YES NOZ Internal Use Only `'1')''
❑ Repair Permit issued in last 5 years ❑ 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
OWNER'S NAME
MAILING ADDRESS
APPLICANT Z;KeA u 'r VA&,>Q' _ V_e S C�Or1
Na e & Relationship (i.e., owner, tenant, contractor)
V ✓TM # �, 3 `_7�1 C�
PHONE #
,L . �t�y Ll7 5'lC
DATE �� �� �% FACILITY TYPE 3 PCHD COMPLAINT # 1"4/N
PROPOSED INSTALLER RD 17J—r1 i PHONE #,5ZG 2-6
ADDRESS �� ��5 i!1` �
�� REGISTRATION /LICENSE #P05 5 70A
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 trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
I, as owner, or reporte ent of owner agree to the conditions stated on this form
SIGNATURE TITLE 0W(1¢� DATE r5t3t 0(p r.
Proposal approved with the followin4 conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditions.
Pro osal Approved Proposal Denied
ip e 5-o/ o
U7pector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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