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BOX 29
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03738
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES NO, Internal Use Only PERMIT__
L LJ/ Repair Permit issued in last 5 years
❑ �� Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland
SITE LOCATION /(D V9000Sl&Ar
4i5 TOWN
OWNER'S NAME
MAILING ADDRESS
APPLICANT
Vot in Watershed
elegated
❑ Joint Review
� # '7q.1 9 Z -1
PHONE #( #WJ S ��
.I'Uf�-sA V k_L� AJV
Name & Relationship (i.e., owrf r, tenant, eontractor)
DATE I,0 o It FACILITY TYPE 5-4 A• PCHD COMPLAINT # '�-
PROPOSED INSTALLER PHONE # % O
ADDRESS �T� 0 yam/ REGISTRATION /LICENSE #
L
Pro osal include a separalte 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 repaai[.
I, as owner,agree to the conditions stated on this form
SIGNATURE ��) Q TITLE d iA1r✓&A- DATE F/Zcf r2o q
(owner)
I- -the se se tics stem repair -
!ic installeri agree to comply. with the conditions of this permit for the
SIGNATURE [ TITLE 0C,,,aRX- DATE oZ -Cko
(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 Qr Proposal Denied ❑
Inspector's Signature & TitIE, ; � D%6 Expirfition Vale
,Repair proposal is in compliance with applicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
LOCAPONS
A
B
c
23
2
29.5'
201
3
451
22.51
4
51.51
30,51
5
57'
37
6.-
7
67"
8.
72
54
9
77
60
10
-821
65.51
86.5
71
12
1-00
81'
13
984'
78'
14
95-51
751.
15
941
731
16
931
71 1
17
92'
69
18-
66
19
921
67.51
20
77'
531
224.46
bAYTIC TANK HAS BEEN ABANDONED
9RDANCE WITH ALL STATE LOCAL
UNTY REQUIREMENTS
06' OF 4 " 5DR -35
® %4 " PER FT.
NEW 1000 GAL.
SEPTIC TANK —�
30' NEW 4" 5DR -35
TO EXISTING PIPE SYSTEM
SET 114 " PER FOOT. i
EXIST. ROOF DRAINS
o EQST.FOOTING DRAINS
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234.23
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of
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/ EXISTING WELL
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FUTURE EXPANSION(TYP.) c �l
END CAPS (TYP.)
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GPRP B �"9� 17
t QPT #1C
f A 4 QR�" 1 16 = t
6
' 8 14
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a 13 i
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CLEANOUT a s 12 �' �``•e�
EXIST. 4" PIPE
. ;SET 1/4" PER FOOT.
PREPARED 8Y.•
retaining ,e�`
s stone o
. rnosonry � F MFyy
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