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03212
eTD Nl� PUTNAM COUNTY HEALTH DEPARTMENT ,N® j'2 S 3
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60 DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_ __PRCkPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR -
YES NO n ^ Internal Use Onfv— ly�. Vi
❑ Repair Permit issued in last 5 years El Not in Waters
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wedarlp,� El Joint Review C
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
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( ANP-LES 4-I-LOM R tCE}A R p S* PHONE #SW 7 3>
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Name & Relationship (.e., owner, tenant, contractor)
DATE _ :Z122-
/0-7 FACILITY TYPE ° 2�S PCHD COMPLAINT #
v PROPOSED INSTALLER ig 6,f (2 r PHONE # FYS
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ADDRESS K6 e) s c-, w4- L�. IZVr REGISTRATION /LICENSE # I _
PU TikC+)VX V i _Le y , IVY.- 10 -5- ?9
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.
_ _Ar, l� - (`(. _ _ �.v 14 E LA) 1006 i;.4(._
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I, as owner, or rep rted agent of owner agree to t44�"*_ s s is q
SIGNATURE 04 1 A TITLE
t of any Town Permit, if dpplicable.
of as built repair sketch in duplicate showing:
tea. 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 ac rdance with the
above proposal and condition
Propo I Approve Ploposal Denied
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DATE ?
ins ctor's S ature & Title Date
PIES: White (PCHD); Yellow (Town BI); Pink (installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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MEMORY TRANSMISSION REPORT
FILE NUMBER
DATE
TO
DOCUMENT PAGES
START TIME
END TIME
SENT PAGES
STATUS
FILE NUMBER 58T
LJrP4,&,M COUNTY HEALTH MEE-P^Ft-rME-Ef,T
0J\oqS1C)N OF MN\of1MC)NMf=-N-rAJ- HEALTH SaM\orlC--SS
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
: 587
: JUL-25 10:5.9AM
: 918455262595
001
JUL-25 10:50AM
JUL-25 10:52AM
001
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CD F400=lr V4"2-dn E`QYC•M 0amcrs. W. Brm—ft or Cretan Pally Rm M naiegnt 31
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AGGRESS 5z C-6= W V5- P4;+ F2IEC31 I--1-rFtJk-nClN n-K--S?-4SF- 'a
Proposal (Include a separate nk*Btczh loCaUng the hCouna. property llnea, all adjacent Wells, within 200
Taot ov repair and the toaflors of awjs,tI"V and proposed trenches)
NcYrs: Repair must be in same location and of same type as cjrjQInsj ftenvege dispoLsm, ny-ste,
0ifferent location and proposed pump myntarna will rekquIra mubmtttaf of proposal from licensecg profsaslonal
ragisterecS architect.
Af
I. as owner. or repofirted agent of owner agree to
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able. CT—H--tp katch In duplicate
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b. Site atrfte�t Nnrnft. Town and -rnx Map number
C. L-ocatlan of imstmllacf components Uad to two fLxea pojntw
d. System dw=C- PtIon (ft-Q.. 1230 amL Conc oW aeptlo tank. etc.)
install—• name and phone nuvvbe,
3. System repair to be parrormeid I a lan wish ce - the
above proposal and conego:
Pro
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--awn,atuire M Title
White 'Yellow Crcn"n E3 1); Rink (Installer). Orange (Applicant)
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