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BOX 33
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PROPOSED INSTALLER LOCO l Gl % e flJW161 -fa PHONE # V YS- '��6 aV7 �
ADDRESS :3 1w AtK -PzLAW REGISTRATION /LICENSE #30374110a 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
I, as owner,agree to the conditions stated n this form [�
SIGNATURE TITLE DATE
W
(owner)
I,-theseptigJflstaHer;a o co plywith'the conditions ofthis pi rmit.fdrthesept]6system repair
SIGNATURE TITLE, ELQ , DATE
(installer)
ProRosal 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 Q Proposal Denied ❑
/9
Inspector's Signature & Title D616 Expiration Date
,Repair proposal is in compliance with applicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
n
-PLITNAM COUNTY-HEALT-1
EPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE
All Information below. must be jUlly completed prior to any scheduling
SITE LOCATION grlh, I TOWN.PUTfAW �A�) TM #
OWNER'S NAME -Toloc> PHONE# -797- �3-
MAILING ADDRESS iv�-
PROPOSED CONTRACTOR/INSTALL ER 1,cacn-1 6� PHONE #,V(/,fS-)6W7/
ADDRESS REGISTRATION /LICENSE# '3aS7A-/10-X-3
82Mn for exalondign:
�Pallure to surface $r- back-up In house ❑ find limits of system for mpaIr P9 other (explain below)
Date
Date: 41 Time:
U
kly:excekseptic
O•
E
PUTNAM COUNTY HEALTH DEPARTMENT"
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
� - 1'F OD _.. .PR ,NT S T h„R P OPL
Y-
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
internal Use Only
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
TOWN iJr^>P1
# t"\ -r-4" `-I --
U Not in Water,
M Delegated
❑ Joint Review
TM #...Gy,1 \- tl - e�
NE # ZY-7 -> 0:1 `/F'& Y
Name & Relationship (I.e., owner, tenanC contractor).)
DATE / sO FACILITY TYPE PCHD COMPLAINT W
PROPOSED INSTALLER OG�q y plum PHONE #
ADDRESS REGISTRATION /LICENSE # 3'Q 374 /0.) 3
-4/1 cf y�-iWo)�
Pr_ oposal (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
I, as owner,agree to the conditions stated�n this form
SIGNATURE 1 ° ;,� �' 1 ,^ } �-- TITLE ;'t -J+ C� DATE
C
(owner) '
I,:the septic.installer; re .to co �? .� itlt e�conditions of.thi perttsii foctfi®.Gspti :system ep ii __ =:.._ - . . - -� --
_. - a9.
7-[SIGNATURE iT : DATE /S
(Installer)
Proposal @poroyed with the followi:Qq conditions:
1. Pmduremeht 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 061rits
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.
f' INTERNAL. USE ONLY
Proposal Approved Proposal Denied ❑
Inspector's Signature & Title ' , I IIDU Expiration Date
Re it proposal Is in compliance with applicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07 40
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Local
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"Finch Lane
Lake. Peekskill, N.Y. 10537
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,79
31
a1 qtr
5-Y
Local
Plumbing / Drain
Inc.
"Finch Lane
Lake. Peekskill, N.Y. 10537
Tel: (8= q I 526-
qj oc �j 247,1!
)NS,7pfq 1000c
rjq /
CoAjc4A,TC- bra, c. —/,.,Jk--
C 0 #lJ AJ -C<,T Tc�
F-i -tl d
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