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04041
PUTNAM COUNTY HEALTH DEPARTMENT
-'` DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROP SAL FOR SEWAGE DISPOSAL SYSTEM REPAIR-
YES NO Internal Use Only
❑ EV Repair Permit issued in last 5 years ZYNot 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
SITE LOCATION I/c, /! TM #
OWNER'S NAME �,�t� o�vul�t PHONE #
MAILING ADDRESS
APPLICANT dt'��� r ,
Name & Relationship (i.e., owner, ten ntr
DATE 0.7 FACILITY TYPE %% 5 PCHD COMPLAINT #
PROPOSED INSTALLER cam- < PHONE # 17 r'ouZ,
ADDRESS t. REGISTRATION /LICENSE # 72
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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as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE �+ TITLE
Proposal approved with the follo ino conditions:
/ 1. Procurement of any Town Permit, if applicable.
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 conditi s.
Proposal Approved Proposal Denied
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JInector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML -- - _
Rev. 8/05
DATE 14V 17
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