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BOX 29
03773
PUTNAM COUNTY HEALTH DEPARTMENT
11 DIVISION OF ENVIRONMENTAL HEALTH SERVICES 4 ® S
P POSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
YESr ... _ <,N. T Internal Use Only
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION � �iit -!3 G- TM # 83 t"I °
OWNER'S NAME �A'Tl2te /G @ ���'� PHONE # . 1�� 3,7
MAILING ADDRESS coTr� �}� Vt6Q-L c/ , j i LOT
APPLICANT
Name &Relationship (i.e., owner, tenant, contractor)
DATE dj FACILITY TYPE r PCHD COMPLAINT #
'Fire 07 W7
kOPOSED INSTA LER &wh" Gl-�9 n %r PHONE
d'Z4,0 LA-1 FLO G' t ADDRESS -t ,411 c V K(_L , (C ISTRATION /LICENSE #
c40 1"?V
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.
I, as owner, or re orted agent of ow r agree to the conditions stated on this form
SIGNATURE TITLE
Proposal approved riththe following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. 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 num er
3. System repair to be performed i ccordance with the
above proposal and condit'on
Proposal Approved Proposal Denied _
Pspeciorr's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05 f�
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