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04706
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Vt PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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Internal Use Only PERMIT #A=VRA�
❑ 97 Repair Permit Issued In last 5 years
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❑
Repair within Boyd's Comers, W. Branch or Craton Falls Res.
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Delegated
Repair within 200 ft. of a watercourse or DEC-mapped wetland
❑
Joint Review
SITE LOCATION
TOWN
TM # C1' -.AY
OWNER'S NAME
J--,F-Vi W KEL:W PHONE#
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MAILING ADD9ES
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APPLICANT
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Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE (-'ZV-S PCHD COMPLAINT #
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PROPOSED INSTALLER PHONE#
ADDRESS 9R4) 0,S CA W A tj A Lt--,, �L p REGISTRATION /LICENSE # 4Q
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Proposal (Include a separate sketch locating the house, so, property lines, all adjacent welle,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 and extent of the repair.
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1, as owner,agree to the conditions stated on this form
SIGNATL1 7//.,..4-L-7 TITLE DATE
(owner)
1, the septic ins Iler, agree to comply with the conditions of this.pOrmit for the septic system repair
SIGNATUR Y TITLEA1 DATE r,(;
(Installer)
Prowsal 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 dupftft 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 guamntee 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.
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Proposal Approved [a Proposal Denied ❑
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Indpector's Signature & Title Dat6 Expitation Date
,Repair proposal is in compliance with applicable codes, Yes No 0
COPIES: PCHD; Owner; Installer
PC-RP 99ML Rev. 2107
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PERSON INTERVIEWED Fuw umplaint i
Name & Relationship (i.e, owner,tenant, etc.)
QDDATE TYPE FACILITY / cam/
PROPOSED INSTALLER PHA rQ�
Pro (include sketch locating all adjacent wells):
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.
Proposal
Inspector's
_ 0
gnature & Title
M
Proposal Disapproved
Ddte
roposal approved 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 (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner,
or r ported
er agree to the above
conditions.
SIGNATURE
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TITLE Y
or
%V
LATE
PHS: TA&te (P D); Yellow Can BI); Pink (Appl.io3nt)