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PUTNAM COUNTY HEALTH DEPARTMENT _��
I�CD
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES N Internal Use Only PERMIT # _ I
❑ Repair Permit issued in last 5 years Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION /TOWN P• T /-. TM #tl>02,�6
OWNER'S NAME &Y-W PHONE #
MAILING ADDRESS y� �� n1� N�� /Tc� f u7`iy.�vg -i ��/�y°Y //✓S`J% 9
APPLICANT��,�
Name & Relationship (i.e., owner, tenant, contractor)
DATE �7 of �%/ FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER �r i••��Aa�Dn.�u �1` e-, PHONE # 9'/4/'
ADDRESS %y( C, iih /�o% �o..kiz� �,J /�ohTJ;REGISTRATION /LICENSE #A C /d V4
Pro sal (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 s bmittal of proposal from licensed profs sional depending on the
nature.and extent of tharep4r. I (I 1 � ) , I
I, as owner,agree to the cond' 'ons stated on this form
SIGNATURE ;�dl l.�zG� --- TITLE Qijo.<f DATE:'
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE TITLE DATE% rS 14 1/
(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
PrilIppr ed E3,6� Pro osal Denied ❑
Insp or's Signa ture & Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07