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v �;K PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES \ 0
YES , � � ~ SNC
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SITE LOCATION
OWNER'S NAME
Internal Use Only i
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 wetland
MAILING ADDRESS
ITTla4Rn_, `111111
❑ Not in Watershed
❑ Delegated
❑ Joint Review
119 TM # &,4 S 2. -v-2 -3t
>4 :M (012�L. & N 24 L- 2. PHONE # c;ZJZ- alb?
Name & Relationship (i.e., owner, tenant, contractor)
DATE `Z FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER a (On 4t PHONE# ;g4(T Sa6 -6) 'J
51% C>KiiWAkM
ADDRESS bra L£ k NJ , f �ot� REGISTRATION /LICENSE # �L. ( 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 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 registered architect_ , „ , ;
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t
I, as owner, or re orted agent of owner agree to the conditions stated on this form J S P
SIGNATUR TITLE E%-1 DATE'
Proposal aoprove with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. 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 cordance with the
above proposal and conditions
T al Approved Pr osal Denied 4. 1"115 1 / 9 LO
Ins ector's Sidiriature & Title / Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
MAY-03-2007 08:54 PM P.01
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Sheet of
PUTNAM COUN- Y�DE -PARTMENT OF.- HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FIELD ACTIVITY REPORT
Street Town State Zip
PERSON IN CHARGE j j Q
nR TNTFR VTFVJF-M k cyr-[, T)atP /
Name and Title / T
TYPE OF FACILITY: =`!EEi(C I�All'1/ik CO it PS's ,
j1/o Ito t�S S �{1 1�7i� • p
FINDINGS:
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I acknowledge receipt of this report: SIGNATURE;��,/'
02/96 Title:
Rev.
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I acknowledge receipt of this report: SIGNATURE;��,/'
02/96 Title:
Rev.
QW`
SITE LOCATION It
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
Yo
TM# 31$
PHONE
PERSON INTERVIEWED PCHD Complaint #
/ i ame &Relationship i.e., owner, tenant, etc.
TE
TYPE FACILITY
PROPOSED INSTALLER &OL41 cc-+6l PHONE" C'Z 6 oZ'�
ADDRESS 65 k i v r VAS GISTRATION# l J�
Proposal (include sketch locating all adjacent wells Y
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
V.
SIGNA
= 1111 1 l r"
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
rt *W
DATE 2 `
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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