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BOX 35
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04663
T-C PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
=WAGE DISPI
YES Nd Internal Use Only U V
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
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❑ ❑ Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review
SITE LOCATION At 44*TM # SU8,
OWNER'S NAME %ke—t4 imro , 6\J 1q 1k- vtt4 PHONE &F
MAILING ADDRESS nhk
APPLICANT W&M
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE Cr-�J PCHD COMPLAINT # �-
PROPOSED INSTALLER uJ cR r PHONE # SU -d. S;F
ADDRESS /y L L/4 LL REGISTRATION /LICENSE # G t y k
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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I, as owner, or r orted agent of owner agree to the condi0ons stated on this form sL,, y�•�1f
SIGNATURE TITLE �f�t DATE e/s-/06
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 aVd phone number
3. System repair to be performed in cordance with the
above proposal and conditions
Pr sal Approved Proposal Denied
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In ector's Signature & Title Dat
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML `
Rev. 8/05 3,
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