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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'ES NO' 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
0 0
❑ Not in Watershed
❑ Delegated
❑ Joint Review
SITE LOCATION a ..._ vo I TM #
OWNER'S NAME PHONE #
MAILING ADDRESS —� ri - n, K, LEI �--
APPLICANT �j C -' I te-14
Name & Relationship (i.e., owner, tenant, ntractor)
DATE FACILITY TYPE C-S PCHD COMPLAINT #
11 kS- jij ji._'r(o ce-I/
PROPOSED INSTALLER s C F�- I Fr f) ► - PHONE # b Yf- 7—t (- 9 �}(
ADDRESS p ZA r t JZ-- REGISTRATION /LICENSE # Z I_
NCI 1 2S
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 reqistered architect.
I, as owner, or reported agent of o n r agree to the conditions stated on this form
SIGN RE TITLE
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2 9Submission 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 and phone number
3. System repair to be performed in accordance with the
above proposal and conditions.
Proposal Approved i�/� Proposal Denied
4 & Title. Date
COPIES:
PC -RP 99ML
Rev. 8 /05
White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
DATE V—/,
"Deaty Calls"
SEP-TECH Inc.
P.O. Box 197 Stormville, New York 12582 -4 —
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845-226-7606
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PUTNAM COUNTY DEPARTMENT OF HEALTH
FIELD ACTIVITY. REPORT
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Street Town State Zip
PERSON IN CHARGE no , - r Date- - - -
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TYPE OF FACILITY :l r—> . 5S T
FINDINGS:
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Ividy Z4 ut vl:�Up �-AX SENDER
1 555-555-1211 p.2
S-OPJECH ha..
P.O. Box 197 Stormvill . e, New York I m 2582
845-22- -9771
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JOE DIGIT...
HI JOE.....
PLEASE FIND ATTACHED THIS PROPOSED SEP'T`IC LEACHING REPAIR FOR 60
CIRCLE DRIVE - TM # 91.25 -2 -3 .... AND ADD IT AS AN ADDENDUM TO THE
PREVIOUS PROPOSAL ENTERED IN APRIL.
PLEASE CONTACT ME IF THIS IS APPROVED THROUGH JOE P, SO WE MAY BEGIN
WORK IMMEDIATELY.
IF NEED BE, I WOULD LIKE TO PICK UP THE PERMIT, SO WE HAVE IT IN HAND.
ANY QUESTIONS, PLEASE CALL ME AT 845 -242 -8658
THANK YOU!
RICH
aan
SE A -T ECH Inc.
�,•..,�� _ P.O. Box 197 StQ rmville, New York 1.25.2
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02/96
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PUTNAM COUNTY..D.E.PARTMENT.OF HEALTI
FIELD ACTIVITY, REPORT
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ADDRESS'. (,4�70 09U9- Aj
Street Town State Zip
PERSON IN CHARGE
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Name and Title
TYPE OF FACILITY: :22W.5-3rs e-epfix
FINDINGS:
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I acknowledge receipt of this report: SIGNATURE;
02/96 Title:
Rev.
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Sheet of
PUTNAM COUNTY DEPARTMENT OF.HEALTH _ 1 +
FIELD ACTIVITY REPORT
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PERSON IN CHARGE
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Name 'd Title
TYPE OF FACILITY: /k SST.S
State
Zip
FINDINGS: 1 fV s a0e` fl o,,) Z,( 4oZ zxW 6nooJ�- 90
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
Rev.