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04061
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
0; 9:241500 1, kI
Internal Use
Repair Permit issued in last 5 years ❑ Not in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
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Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
�� �i�,�%i� ///G /�l17�.�aa� �i��l�► TM #
Lcc PHONE # :✓W-6'03 /! L
Name &
tenant, contractor)
DATE / d� FACILITY TYPE S'� S PCHD COMPLAINT #
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PROPOSED INSTALLER PHONE#
ADDRESS 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 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.
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATUR TITLE �E3`i`Li.c T
Proposal approved with the fo win4 conditions:
t_- Rcocurement of any Town Permit, if applicable.
mission 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 conditions.
Proposal Approved Proposal Denied
In ector's Signature & Title C ` Date
COPIES: White (PCHD); Yellow (Town BI); Pink (installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
DATE
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