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BOX 32
04170
PUTNAM COUNTY HEALTH DEPARTMENTS
DIVISION OF ENVIRONMENTAL HEALTH SERVICES C) r
. PROPOSAL FiDA SEWAGE. -TR ` .
E�4TAAE9�T'SYSTER9. REPAfR .- ......
Li LA Repair Permit issued in last 5 years
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetlarn
SITE LOCATION INY Ott i.O 4C .5.7, TOW N
OWNER'S NAME 2V-7. 1,414
MAILING ADDRESS, 1 it (oc ' St, 1AI<cc Pv IF is
APPLICANT °f-4d L L/i4f .n 64 &A-4 sra °F .
IJ U
PERmirrit
❑ Not in Watershed
❑ Delegated
i ❑ Joint Review
TM # 3 o iS-- / —/ )
l�E# Sn - /S31
K(bl t h,-4
Name & Relationship (i.e., owner, tenant, contractor) —
DATE FACILITY TYPE R9 r PCHD COMPLAINT #
.
-71- V-7 INSTALLER w k PHONE # hUc s^
�' 08
ADDRESS
REGISTRATION, /LICENSE # 16 Y 3
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.
_ -r r. t' 6%S
z i S
I, as owner,agree . the cond�ns stated on this form
t
SIGNATURE !f TITLE itci�'kn. DATE
(owner)
F, the septic ins Ile,, agree to comply with the coridtions of this permit for the septic system repair
SIGNATU TITLE DATE 6&h i
(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 back�fed until authorization to do so has been obtained from the Department.
/ INTERNAL USE ONLY
Pr proved 1Y P3 os I Denied
Inspe or's S)gnature& Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes f No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
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