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04169
1� PUTNAM COUNTY HEALTH DEPARTMENT ,„ Iva. 415e ,
DIVISION OF ENVIRONMENTAL HEALTH SERVICES .
A I r=O%r% Ar \• /A Ar !\lAl%AA A a A\ /lATrf■ ■ hs— � A ■A
YES
Nq Internal Use Only
L-5
❑
Repair Permit issued in last 5 years
❑
Not 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 �4 7 BSciwA it Lk, 121) ,l (•a CPIitGLff- - 'r TM #
OWNER'S NAME 6AAN tOL ` lks SI f}Tcc..,+C ti'f T, PHONE #9Se4�S"ol /S7t7
MAILING ADDRESS 11e Pee 1 <9 K +L6 JN-4
APPLICANT
Tz�GE. Z-1
Name & Relationship (i.e., owner, tenant, contractor)
DATE Lv7 FACILITY TYPES S PCHD COMPLAINT #
PROPOSED INSTALLER PHONE # 5-72—E 5—
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ADDRESS fY 1-14 SAI V 1�0 -C j+, J`1•�- /OS�EGISTRATION /LICENSE # �'? C
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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 registere architect.
ek Q_ 4�. 5• 6 ST -r,+Ht R tae -R-ct. l o o cdv c
�r— �.:Z�i��•r'•i���Slit�r`IIe+ `!L!��l�i�%T'lZ3F�! ' �
I, as owner, or r ported agen r ethd conditions stated on his form t� -,
SIGNATURE TITLE .46,�r DATE t
Proposal approved with the following conditions:
/ rocurement of any Town Permit, if applicable.
2. ubmission 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 r',x
Pro osal App ed Proposal Denied : `
C In pector's Signature & Title Date
OPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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acknowledge
slic'et of
PUTNAM u
-CO NTY DEPARTMENT ]:OF ;HEALTH
DIVISION%
-OF ENVIRONM.-ENT-A--L'HEAT—LH SERVICES
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street Town State vd:q
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Name and Title
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°ceipt of ibis report:
SIGNATURE:
'Title,