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BOX 30
03855
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YES NC
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
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PUTNAM COUNTY HEALTH DEPARTMENT •
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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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
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Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER p W A PO GPAJO F Xo l PHONE #
ADDRESS �C%® �1�CR�i%N04 C�I�. jZ y, REGISTRATION /LICENSE # rC 139
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.
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I, as owner, or re orted agent of owner agree to the conditions stated on this form �' ui'ur
SIGNATURE aj TITLE ,Ct ---r DATE 2,r
Proposal approved with the following conditions:
. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owners 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 number
3. System repair to be performed in accordance with the
above proposal and conditio
Proposal App` ve Proposal Denied
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spector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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