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85.06 -1 -21
BOX 34
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPA...
Y NO Internal Use Only PERMIT# ,� °-G�h(o —!
—7 Repair Permit issued in last 5 years — TnlG VDelegated
ot in Watershed
c3 & Repair within Boyd's Comers, W. Branch or Croton Falls Res.
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION `� ��cca�v cz � TOWN//%2�w TM
OWNER'S NAME ��r•,.cPAO L, /Z--/ PHONE #
MAILING ADDRESS
APPLICANT
Mill
' Name & Relationship (i.e)-owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED IN TALLER S/ j ,,, s _ K( PHONE # ge
ADDRESS 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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature qad extent of the repair.
I, as owner,agree to the conditions stated on this form
SIGNATURE . ,. / TITLE DATE / / CJ
(owner)
I, the septic in alter, agre , o comply with the conditions of this permit for the septic system epair
SIGNATURE,, �3,- r,./(� TITLE DATE y lx)v
(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 Proposal Denied ❑
)�),( W46/i �///
nspector's Signature &Tifld D e Ex ration Date
Repair proposal is in compliance with applicable codes Yes O No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF EN VIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
Street Town State Zip
PERSON IN CHARGE
OR TNTFR VTFWF.D-. T)atP_
Name and Title
TYPE OF FACILITY:
FINDINGS:
y
TNCPFCTQR' Tr'
Signature and Title
R FPIIR T RFC- FTVFT7 BY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
F �
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use
PERMIT-# -1-')-
4 10
Ll EIJ /Repair Permit issued in last 5 years I_1 >Mt in Watershed
❑ V Repair within Boyd's Corners, W. Branch or Croton Falls Res. Lill, Delegated
1:1 Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
TOWN (% TM #S
PHONE #py� ?
t-
Name & Relationship (i.e., owner, tenant, contractor)
DATE It d. va FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER O U4 t, ; Qr" (o "7- PHONE #
ADDRESS At/t_ REGISTRATION /LICENSE # ' 7 r
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
4 _Z 46,.
I, as owner,agre the conditions stated on this form
SIGNATUR TITLE DATE 1 O
I, the septic installer, agree to the conditions of this`pefmit for the septic system - repair
SIGNATURE <1 TITLE . � DATE _)/l S O T
(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 Proposal Denied ❑
t /
Inspector's Signature & Title D to� Expiration Date
Repair proposal is in compliance with applicable,codes Yes lam" No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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34 "!Columbus Ave Putnam Valley N.Y. 10579 914 -760 6344
Flannery IM-85.6.4-21 Date 7/15/09
9' Taconic Gate - License # 113 7
Putnain Valley N.Y. 10579
Replace existing metal-tank with 1000 Gall on concrete tank.
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Al 21.0 :B_1270
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