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BOX 32
04204
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04204
la PUTNAM COUNTY HEALTH DEPARTMENT
° DIVISION OF ENVIRONMENTAL HEALTH SERVICES
, ..PROPQSAL FOR SEWe4GE. TREATAAE f��'= �Yc�- TEIVI.�dEPd�IR-
YES N-911. Internal Use Only PERMIT #/
LJ Repair Permit issued in last 5 years LvJ',N%t in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton f=alls Res. Y Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION Mime-519 TOWN �u f• VA I L1 , TM # :F3, 2p
OWNER'S NAME :Tr�hra I���.uc Cg- ;L4,oc�LL PHONE # 52,fj -3363
MAILING ADDRESS
APPLICANT
Name & Relationship (i.e., owner, ten eon o
DATE 05 FACILITY TYPE gp PCHD COMPLAINT # SOY
PROPOSED INSTALLER ,/12yw e �oG. , PHONE #
ADDRESS IS Agpju.. cT ii�D�L.c t1 S� i+T REGISTRATION /LICENSE # 161-7
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.
re, �l /, 000, 44s /'1&— pe 4 , T•�,/C . 'i✓� cscc� -sue 4 ya- 4v agg, l/ A ca. +- g,4
/ S n YY1 — Z, r-0. °-ia rt r
I, as owner,agree the nditio stated on this form
SIGNATURE TITLE oz<.alC,L DATE 14 &4,
(owner)
_ - -- — -•-I; the septic instaftr, aagree to co m ly with-the conditions of-this permit °for the,septic"systerrrrepair
SIGNATURE - TITLE DATE / 6r
(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.
INTERNAL USE ONLY
Proposal Approved Qf Proposal Denied ❑
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In pector's Signature & Title. Dat6 Exp 'iratiorf Date
Reoair or000sal is in compliance with applicable codes Yes O No _a
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
JOB
ARROW EXCAVATING, INC. SHEETNO.11 OF
15 AVALON COURT
HOPEWELL JCT., NY 12533 CALCULATED BY. DATE
-227.4505; (91-4'Y1528-w4395-'-.-
-,7(845) CHECKEDBY --- DATE