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BOX 27
03428
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03428
SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
TREATM
Internal Use Only PERMIT#
Repair Permit issued in last 5 years ❑
Repair within Boyd's Comers, W. Branch or Croton Falls Res. 21
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑
OWNER'S NAME �r
MAILING ADDRESS '.??
APPLICANT A .11/./11 s"
0
JR,
t in Watershed
Delegated
Joint Review
TOWN ( TM #
PHONE #
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER �_ I /ZIn 1'_ PHONE #
ADDRESS << ��� ! J4 LY rA I�. X REGISTRATION /LICENSE # 1170
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Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 20,0
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 reDair.
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner) '
agree to comply with the-conditions �6f'this-0er''mftl6Pthd,�eptic sy"stemr repair
SIGNATURE A�. �� -y��• TITLE /jls%A/6' ' DATE eJ -�2, -T �
(installer)
Proposal approved 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.
INTERNAL USE ONLY
Proposal Approved V1 Proposal Denied ❑
Inspector's Signature & Title D to Expiration Date
,Repair proposal is in compliance with applicable codes Yes ❑ No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
PLMM OOUNTY RMUM DEPAR24W
DVISION OF ENMONMEMM MMM SUMCBS
PROPOSAL FM SERPM DISPWAL SyS�
Install 300 LZF of 2' leaching trenches° old system
consisted of 150 ' LIF of 2' ,trenches.
ftoomal approved Proposal Disapproved'
Inspector's Sigmture I,
.Sam 9i
19 as owner, or reported agent of owner agree to the above omxUtims.
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Sheet i of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISI. C�1�OF ;NV1:R.NIVIENTA]L_I3EATLII SERVICES
-FIELD -
ACTIVITY REPORT
Tel:
Aj]T)RF.44; ��UJ4/1
Street Town State Zip
PERSON IN CHARGE
OR TNTF.R VTFIVFT): . et/EAiS t tz_PTlG
Name and Title
TYPE OF FACILITY:
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Signature and Title
REPORT RF_CFTV'Fn BY:
I acknowledge receipt of this report: SIGNATURE:
02/96
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
s; � �3u SIGN GYt:J� 1f2Q 1:VI 1 1L Ii A I :: l[ --SKkv
FIELD ACTIVITY REPORT
ADT)RFSS'
Street Town State' Zip
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02/96
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