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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use Only PERMIT-#
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Li ® Repair Permit issued in last 5 years ❑ of in Watershed
❑ . W,,.-'Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ 13' within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION TOWN � . k ktk- \\ TM # q —
OWNER'S NAME L.is PHONE# >0-17
MAILING ADDRESS \A �� �", �,,+ ��, ���� hy.Q
APPLICANT 0 V,.,Am%,A —
Name & Relationship (i.e., owner, tenant c n Tctor
DATE 9<. L, Do( FACILITY TYPE S'L,,����Q PCHD COMPLAINT #
PROPOSED INSTALLER ., Q. `'�i� Q� \O�._, PHONE # %k�4 - q\ . btZo
ADDRESS Q(D 41ti REGISTRATION /LICENSE # � C3%5
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 con 'tions stated on this form
SIGNATURE a TITLE DATE
(owner)
: . c sP
septic. e lt _v , .9r or" n ' ^w.��-� of -th;s Permit t fo, t e'sapt.
c s tCf f E ai�- Cr ply .� ... __..._ .__.a
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SIGNATURE C TITLE qyu_� DATE
(installer), Proposal approved with the following 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 fit 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.
1W 1 CMNAL UJC UNLT
Proposal Approved Proposal Denied ❑
Ins ector's Signature & 11ftle Dat4 I Expiration Date
,Repair proposal is in compliance with applicable codes Yes 0 No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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,..M on v .Ord?►-. �►��ed�res . .e.,,. ,, ., � . �... r r . ,s � � . _ a:.:.
1. Determine amount needed to. purchase permit (Putnam County Health
Dept is $150.00).
2. Obtain cash from Accounts Payable. If Accounts Payable is unavailable,
get cash from Clint. If Clint is out of the office, call Clint or Dave.
3. Give cash to person buying money order. Instruct person buying money
order where to purchase money order (use list below or look up on
western union.com for location to purchase).
4. Instruct person buying money order to return receipt and stub for money
order with paperwork. They can fill in the "Pay To" information at the place
they are paying for permit. /---
Dutchess County
A &P #094
Rte 44 & North Ave
Pleasant Valley, NY 12569
845.635.1053
Hours: 8am —I Opm
Pleasant Valley Post Office
1612 Main Street
Pleasant Valley, NY 12569
845.635.8932
Hours: M — F 9am — 5pm
Smokes 4 Less
17 North Ave
Pleasant Valley, NY 12569 -7943 U
845.635.1053
Hours: M -F 9am — 8pm
Sat 9am — 7pm
_. ._._ .....
_.
Putnam County
A &P #154
Route 22
Brewster, NY 10509
845.278.5282
Hours: 9am — 8pm
Hannaford Supermarket #325
1936 US Route 6
Carmel, NY 10512
845.225.4151
Hours: 7am — 9pm
Rite Aid #3656
1511 Route 22 Suite A
Lakeview Plaza
Brewster, NY 10509 -4009
845.278.5251
Hours: gam — 9pm
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Permit 9 R- 202 -09
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TM # 8374 -1 -30
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7 As Built Drawing
SHED
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A= 19'3"
HOUSE TO INLET COVER
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B= 7 3"
HOUSE TO INLET COVER
B 4 HOUSE
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C= 6'
OUTLET COVER TO D -BOX
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D= 10 9"
OUT LET TO D -BOX
HOUSE.'`
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NOT TO
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NOT TO SCALE
NOT TO SCA %E
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