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03153
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
)SAL S:WGr?4,OpC TREATMENT SYSTEM REPS
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Internal Use On
F1 ff Repair Permit issued in last 5 years
Repair within Boyd's Corners, W. Branch or Croton Falls Res.
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland
PERMIT # �J� "(
VNot in Watershed
Delegated
❑ Joint Review
SITE LOCATION t�gy1Cw�. ``y 4.. �,cTOWN i TM #
OWNER'S NAME ° �Ul �+(, v-c d PHONE
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#
MAILING ADDRESS i 'ettL U�o� �0 C UPS
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE C 7 FACILITY TYPE PCHD COMPLAINT # < ell
PROPOSED INSTALLER j. CLf/t PHONE # �gS—IB 3Z - 010 � ' ZZZ
ADDRESS `e �[t L %1lU 0.l f,, REGISTRATION /LICENSE # 3 l3
Proposal (include a separate sketch, locating the house, roperty lines,/ all adjacent wells within 200
feet of repair and the location oflexisting and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair..
I 6V Sr c ,r C i9n IC
I, as owner,a to the coriditioris stated on this form _
SIGNA R �����'Z° `�'` 1,142 TITLE(�) Cy VZ,V DATE
.:: lrivnerN.
•at. 4� li�'tnnc..�f }V-,ic . Pr I� T r t u si o
I, the septic installer, agree to cuirlNiy wrlll 1: cc,;�,;.�;,� _.p :m- .o. he s ptic sy�_em r plr
SIGNAT -bRE� 1 TITLE yGil'fii�O` DATE ✓— G'
(instalierj
Proposal approved with the following conditions:
1. Procuement of any Town Permit, if applicable.
2. Subrrission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Ormer's name, Site Street Name, Town and Tar, Map number
b. Location of installed components tied to two fixed points
c. Sistem description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Irstallers' name and phone number
3. Syst:rn repair to be performed in accordance with the above proposal and conditions
A. Theroposed 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:ompleted work is to be backfilled until authorization to do so has been obtained from the Department.
IIV I CI'f IVHL UJC VIVLT
Proposil Approved Proposal Denied ❑
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Inspecnr's Signature & Title Ddte Expirati n Date
Repa0roposal is in compliance with applicable codes Yes No ❑
COP IS: PCHD; Owner; Installer
PC -R) 99ML Rev. 2/07
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Sheet ( of (
PUTNAM COUNTY DEPARTMENT. OF HEALTH
rVISID l -OF-E- 'VfRTNi�iEN'fA — REA` Lft SERVICES
FIELD ACTIVITY REPORT
enngFcc• 913 A1rv,4&i 4AKE 0 4 AyMJ.4A i/A(-Zg'l A),X ,,
Street Town State Zip
PERSON IN CHARGE J
op TNTFT2 VTF\J p. T'atf
Name and Title
TYPE OF FACILITY: J�,e
Signature and Title
I acknowledge receipt of this report: SIGNATURE:
nq /9h Title:
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