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03872
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_. .._..,:.. - - -.._ SEWAGE E DISPQSAL SY
STEA,REPAI
YES NO / Internal Use Only
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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
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Not in Watershed
Delegated
Joint Review
SITE LOCATION
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TM #
P, 0 -3
OWNER'S NAME
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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
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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
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nature & Title � to
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
Pt'-RP 99ML
Rev. 8/05
DATE � ".�- -aZ-
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