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BOX 33
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04316
PUT NAM COUNTY HEALTH DEPARTMENT (S�
r DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OPOSAL-fOR - SEW -AGE T- REATMENT SYSTEM : REP -AW
YES NO/ Intemal Use Only PERMIT # -
❑ Repair Permit issued in last 5 years WNot in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ Repair within 200 ft. of p watercoyrse or pEC- mapped wetland ❑ Joint Review
SITE LOCATION 18 Ilk
OWNER'S NAME
MAILING ADDRESS
APPLICANT
/ / /e- TM # J7 To "
I,(A.r_ PHONE #
Name & Relationship (i.e., owner, tenant, contractor)
DATE 1X FACILITY TYPE 12eS PCHD COMPLAINT #
PROPOSED INSTALLER if PHONE # 'q/l `"Dk4- it
ADDRESS % REGISTRATION /LICENSE # /42
ProQosal (Include a separate sketch locating the house, property lines, all adjacent wells within 200
feet 4r, epair 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. � J
I, as owner,agree to
SIGNATURE
(owner) ..
--1 -the septieinstaflar;
conditions
In
this form
DATE
conditions'of this'pe- tit -for the4eptic-syitem repair'
SIGNATURE TITLE DATE
(installer) �
ProROW ARRUM d 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
Pr po I Approv 3 Proposal enied U
'
IL
Ins or's Signature & Title %(t At Date _ / Expiration Date
,Repair proposal is in compliance with applicable codes Yes EV No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Sheet 0
PUTNAM COUNTY DEPARTMENT OF.HEALTII
DIVISION OF ENVIRONMENTAL'REAtTil S99VICE9.
FIELD ACTIVITY. REPORT
ke-- N01 04Ur
ADT)R S S 1 Z59 P §
Street
PERSON IN CHARGE
OR TNTRRVTF-WRT)-.
Name and Title
TYPE OF FACILITY: SST5
WOUV W
Town
State
zi
00, �'
9
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INSP CTQR: a4 TR I
Signature and Title
R'FPORT RF.C.F.TVE-T) TAVI•
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
Rev.
r, 11
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Sheet l Of
PUTNAM COUNTY DEPARTMENT OF HEALTH
..,4:";-,;; �r']MV-'ISION-OFEN-V-IR,O1�1 ENT-A,L-41EATLIISER-VIC.-E,g
FIELD ACTIVITY REPORT
NAMP:
L IVY
A1)nR A, 0 W
Street Town State F Zip
PERSON IN CHARGE
OR TNTF.RVrRVFTC:
Name a Titl
TYPE OF FACILITY: 5515
FINDINGS:
Signature and Title
R'FPn'RT RF-C.FTVFT) RV:
I acknowledge receipt of this report: SIGNATURE;
02/96 Title:
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