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BOX 32
04218
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04218
PUTNAM COUNTY HEALTH DEPARTMENT ��
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ! ,�
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
YES NO Internal Use Only
❑ Repair Permit issued in last 5 years Not in Watershed
❑ ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res.
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland
SITE LOCATION �i ✓ Al Vd -
OWNER'S NAME
MAILING ADDRESS
❑ Delegated
❑ Joint Review
TM #
PHONE #- -Qi1rs
u K 'Y• 1106-37
APPLICANT _�12.4 vc
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE
PROPOSED INSTALLER Cleats
PCHD COMPLAINT #
PHONE # g /y-7. oo- 7Q /,(,
ADDRESS �� , ro /yX L)r • C.s 4yW oil 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 re Istered architect.
AW
4K4 r'o
s _ �P
I, as owner, o re orted agent of ownerogW to the conditions stated on this form
SIGNATU TITLE [�l�
1 Proc nt of any Town Permit, if applicable.
Submission 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.
Anspector's osal App r ved Prop , al Denied
-71-7 106
Signature & Title 21 C, Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
l ie_ s�c! w`'►i •t - r -t- t fei k5 Cti.s-z
Its 841.x! pe."Aa
DATE
AS BUILT DRAWING
eml
I go's . 06
Leonardi & Son Construction, Inc. .Date:
6 Carolyn Dr. Cortlandt Manor 10567
(914) 736-9010