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BOX 31
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PUTNAM COUNTY HEALTH DEPARTMENT 0 I
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR U "
YES NOL Internal Use Only PERMIT # R 002 1
a 96 / Repair Permit issued in last 5 years Y Not in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ E Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 3V Lk' iQ I Z - TOWN V TM #
OWNER'S.NAME 6 -e-,;r 1p ,r' PHONE #
MAILING ADDRESS (,y-
�Z
APPLICANT
Name & Relationship p.e., owner, tenant° or
DATE ',J _ FACILITY TYPE :5T S PCHD COMPLAINT #
PROPOSED INS AC L& �ct✓ �d <.._ r_.. PHONE #
ADDRESS",, _ jJ°,y��,l,,., �/ REGISTRATION /LICENSE #
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 extent of the repair.
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE �wl,t,�,r DATE
(owner)
I, the septic installe gree to comply with the conditions of this permit for the septic system repair
SIGNATURE� TITLE y� 2 "� �f DATE,;
(installer) :' �
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 ft 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.
INTERNAL USE ONLY
Pr po I pro C� Proposal Denied ❑
Ins or's Signature & Title Date Expiration Date
Re it proposal is in compliance with applicable codes Yes a// No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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41
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ARROW EXCAVATING, INC.
15 AVALON COURT
"Mat HOPEWELL JCT., NY 12533
(845) 227 -4505 (914) 528 -4395
roe ;��,y� � /�
SHEETNO. ` SAWY NN Lit l�`tti. OF I�+r
CALCULATED BY
CHECKED BY.
DATE ` —L 0401
DATE
PRODUCT 204 -1(Sh* Units) 205.1(W
• 1
SIT]
MAILING ADDRESS V-0, Llp x W ex i F 4 u -e We k-( K, a ki +.I I a 5 3)
DATE
PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PROPOSED INSTALLER ��r. r,► s V - Mar-'z , % CAW 0 ",
PHONE gt !+i 4o. -�3
Pr sal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
RP .: --T' �% e. &-r- rz,t --' r S N. e- C-
s
Proposal approved Proposal Disapproved
Inspector's Signature /-& Title Date/
Proposal approved 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 (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE._/. TITLEi�^ DATE
OFIHS: V&te (EM); YeUea (fin ED; Pink (ARAimnt)
TITLE No.
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SURVEY OFPROPERP�
011 PAIII I 1 11;11
CHARLES R. & JEANNE M. MACK
TOWN OF PUTNAM VALLEY
PUTNAM COUNTY NEW YORK
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NOTES:
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