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03462
PUTNAM COUNTY HEALTH DEPARTMENT p
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL. FOR SEWAGE TREATMENT SYSTEM REPAIR
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NO Internal Use Only PERMIT #- .,.,
❑ EX Repair Permit issued in last 5 years "Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ur,��/ Repair within 200 ft. of a watercourse or DEC- mapaed wetland ❑ Joint Review
SITE LOCATION cc, WN QJ17V�.rL w• (,jst;l M # ,7
OWNER'S NAME _ e (, p PH�E # I y- — r/ 90
MAILING ADDRESS c-, vv\ e.si a O pct i "-: , vA,,o7 A,0-1, /, _ey-7 S
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE t.A i, i I 1 ti FACILITY TYPE R PCHD COMPLAINT #
PROPOSED INSTALLER
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PHONE #
ADDRESS
PX,nk —U' 4-
JREGISTRATION /LICENSE #
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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and /extent of the repair.
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!K .P_n //ir P --i-a' /c, P a c- Cur,, vai
I, as owner,agree t th ca nditions t ted on this form
SIGNATURE J, TITLE (9 C-J4-I er DATE lD
(owner)
the,:s PrtiC hsfa,111y .,ac red io C�iil.°,'J withrt�e core ltl ns of this permit: for the septic system repair
SIGNATURE TITLE' DATE
(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.
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Proposal Ap roved Proposal Denied ❑
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Inspect E pirati n Date
,0% Signfiture & Title Re it proposal is in compliance with applicable codes Yes ❑ No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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Putnam County Department of Health - Division of Environmental Health Services
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14 SSTS Repair - Fin ite Inspection
Date: 6 ` Inspected by: P342,P6 Installer:
Str e t Loc t
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Town:• - - Repair Permit #:.S - - _TM # . �. ��� 3%
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1. Was System inspected? Yes CK No ❑ If not, explain:
2. Type of System: Conventional 0 Alternate ❑ Comments:
3. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size 1 ... 1,250 ... other .....
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b. Septic tank installed level ......................
4. Distribution Box
a All outlets at same elevation (water tested) .. .
5. Junction Box - properly set ...........................
6. Trenches
a. System completely opened for inspection
b. Length required Length installed
c. Pipe slope checked ... ...............................
d. Installed according to plan ......................
e. Size of gravel 3/a - 1 '/Z " diameter clean .........
... .. :. r�gr +h. et ^*2aIPl an
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g. Ends capped .... ...............................
7. Pump or Dosed Systems
& Sewage System Area .
a. SSTS Area located as per approved plans
b. Fill section -
c. Distance from water course /wetlands
9. Overall Workmanship
a. Boxes properly grouted and installed correctly ...........
b. Backfill material contains stones <4" diameter .........
c. Curtain drain & standpipes installed according to plan
d. Curtain drain outfall protected & dir to exist watercourse
e. Erosion control provided ............................
COPIES: PCHD; Owner; Installer RFSI Rev - 011916