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HomeMy WebLinkAbout3872DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -3 -69 BOX 30 so J r goo , 91 ., 9ti .i LP r 16 L i I. it , . 03872 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES _. .._..,:.. - - -.._ SEWAGE E DISPQSAL SY STEA,REPAI YES NO / Internal Use Only ❑ ❑ ❑ [!T ❑ ❑ 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 ❑ ❑ Not in Watershed Delegated Joint Review SITE LOCATION �O ,L/o�� �'i�1 �� TM # P, 0 -3 OWNER'S NAME lf4 /e.z,7 G?;,d �./ PHONE # MAILING ADDRESS APPLICANT � IltZQ Tin}, 41k'1A21 Grp Na e & Relationship (i.e., o ner, tenant, contractor) DATE ,?- )- -0 I' FACILITY TYPE 10I'le PCHD COMPLAINT # PROPOSED INSTALLER PHONE # ADDRESS 37 G,,,e_ /:;ir, /?Z REGISTRATION /LICENSE # J% C IP3 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. 10 ...Fl "7f 3�, ` /�;.d_ . ...,�P- ...��� %�......_..__ mlZ rye '74P& Z's /4, 4�- // 7o 1.✓�.�'rr 5�., �, �' � �st .p ,� 1. r_ , . I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE cn„ /� TITLE 4i de-/• Proposal app ed with the 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 number 3. System repair to be performed in accordance with the above proposal and conditions. Opector's sal Approved Proposal Denied f � � nature & Title � to COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) Pt'-RP 99ML Rev. 8/05 DATE � ".�- -aZ- Sheet of 11Z COUN I?4' JDEPAIltTMENT ®JF HEAL`T'H ir's DPiSYON�0,T EN�It�T11ViENTAZ HEATL SEiZVICES Title, �,. r• w o s ` , 1 55 S 90 Q . BB : 2W { 1 �2 ~' . g 68 51 Ztip 70 Q �.o so S 0 'oo Jo0 4? �RTMOUTH / loo Wt 1Y SGt� `.e too RUAQ 100 X00 8 72 '�0 S w 71 w • Y 4 V ''- �--- -. 100 Ak t A J