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BOX 29
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03775
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- P.ROPO.SAL FOR SEWAGE TREATMENT- SYSTEM REPAIR
.. _ _ �: .,. --- =_- - •--:... .- , ...- - ,...,...._:.e..•� - �, - ��'-- ,tea /:'- .,
YES NO _ Internal Use Only PERMIT #
U❑ V Repair Permit issued in last 5 years koloo'Not in Watershed
Yle Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ Repair within 200 ft. of a watercourse or DEC - manned wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT I�i4 J t
LA/ TOWN V,, D rj*w �,� f (l� TM # T3, -1 — 1 s
4e /u y PHONE #SWAY- -F 3 $ < y
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co4o --I 61tf n/a
ame & Relationship (i.e., owner, tenant, contractor)
DATE / r / FACILITY TYPE ,Sir�r`C r5►•rw PCHD COMPLAINT #
PROPOSED INSTALLER ZO CW, Guy MOK'K/ 'vt PHONE # R WS; c) `7r i
ADDRESS 3 -r CU4 REGISTRATION /LICENSE # IfC3037A X3-3
N <rrs-3-
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 xtent of the repair. �°
fU 0 60-1 �SRi-e 74 ^ t ri I /A Mft�% yy 14'A ins o G'.s
I, as owner,agree to the conditions stated on this form
SIGNATURE C. TITLE O"u^^elL DATE 5- 17 1 / S`
(owner)
- °- - - - I, thE'serti nstu Qr.; �iglro to .c6.melvith.tfie.r.9ndit(br) of this- eermit for the septic system repair -
SIGNATURE TITLE 10W-44 DATE
(installer)
Proposal aQproved 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. -
INTFQIJAI I QN AM V
Proposal Approved Proposal Denied ❑
S-// I h s �z t t
lWectdFs Signature & Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes ❑ No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
SJa��j_
Putnam County Department of Health - Division of Environmental Health Services
SSTS Repair — Final Site �I.,nspec ' n
Date: ✓ ! �- / Inspected by: �� ;� Cie edC Installer:
Street Loc tion: citi Owner: Ke 1he ePa P ca :y!_�s _ ..TM_ #_ -,
::R it P emit -M. . /. -
1. Was System inspected? Yes No ❑ If not, explain:
2. Type of System: Conventional GrAlternate 11 Comments:
3. Septic Tank
Yes
No
N/A
Comments
a. Septic tank si — 1,000,,,/. 1,250 ... other.....
b. Septic tank installed level ..................:...
4. Distribution Boxes
a. All outlets at same elevation (water tested) ...
5. Junction Box — properly set ...........................
6. Trenches
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a. System completely opened for inspection
b. Length required Length. installed
c. Pipe slope checked ... ...............................
d. Installed according to plan .....................
e. Size of gravel '/e - 1 %2 " diameter clean .........
r. Depth of gravel nY tr. zich 12" minima..:::
g. Ends capped ..... :..............................
7. Pump or Dosed Systems
8. Sewa¢e 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 ............................
RFSI Rev - 010515
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