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631 - 589 -8100
3.19 -1 -79
BOX 2
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IN 11
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00100
SITE LOCATION
OWNER'S NAME
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES a
PR POSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
NO Internal Use OnlyC��-►d
i /F Repair Permit issued in last 5 years ❑ in Watershed
Repair within Boyd's Comers, W. Branch or Croton Fails Res. Delegated
Li Repair within 200 ft. of a watercourse or DEC - mapped Welland ❑ Joint Review
MAILING ADDRESS
COO �- t R
APPLICANT �pyL-} -rrC
Name & Relationship (i.e., owner, tenant, contractor)
DATE i () I O FACILITY TYPE CHD COMPLAINT #
3
PROPOSED INSTALLER PHONE # %6-- CiOC�I
ADDRESS 44, 2A11- v)ci REGIS*
EGISTRATION /LICENSE # - �-
l� lyC sAg�, r1�ax��.11 a_v
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.
�.»,L r 'eSk�rG�
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
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 proved Proposal Denied
Z/ le96
I spector's Signature Urihe Date'
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Sent By: MR ROOTER PLUMBING;
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Sent By: MR ROOTER PLUMBING;
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Page 2/3
NOU -1 -2886 klED I.J.::_ "A TEL:845- 278 -7' 81 NAh1E:PUTNAM COUNTY DEPARTMENT OF P. 2
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SWAGE DISPOSAL SYSTEM REPAIR
YE
NQ internal use only
❑
.. Repair Permit issued in las! years LJ Not in Watershed
17
-r✓ Repalr within Bcyd's Comers:, W, Branch or Croton Falls Res. La Delegated
U
L�Repair within 2D0 ft. of a wat rrcourse or DEC -map ed wetland ❑ ,Joint Review
SITE LO
ATION ':3 Atzrr r' (-7 I tILL; R.-P> , M A H 0'r-A TM
OWNER
S NAME C (11 Cle (, A N. C -PI rZ i 7 �t{F PHONE
MAILINC
ADDRESS S(tiNt��
APPLIC
NT /v1 r1, t<ou � Z PcvAU3j (T { i"i.umaP
Name & Relationship (i.e., o ner, tenant, contractor)
DATE
Iv 1 r -o j -FACILITY TYPE, k, PCHD COMPLAINT #
PROPOSED
INSTALLER M�� Ru� -76'Z p(.6- CioiT._ _ PHONE#
ADDRt=
S `,- - -`.�` ;7 j:r)Gh +_ I'iL-w.j A,�7 v&tr1 REGIMATION /LICENSE # l "�'. :Z' =i �f� -/?
N
Propose'
(Include a separate sketch locating the house, prolmrty linos, all adjacent wells within 200
feet. of r
pair and the location of existing anq proposed trenches)
NOTE:
epair must be in same location and of Oame type as original sewage disposal system.
Different
ocation and proposed pump systems Will require subrri ttel of pr6posal from licensed professional
engineer
or registered architect,
t+�rua
i �_Y:� (�ifaCtt?►i s�Y �,� -��,� _, -.., ,r,,,.
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o I N c L v? � E^P r rt F_r
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J_ kA&It. M,4bF C) F C0 0i 1'7f2V -71p,-1 10(.K- C L✓t ja i'� -IY E CA�raL
a,RA!!r
� (,At L✓i'tn ��' IN�rLK/1`70C� �V T,S/(tlii
1, as ow
r, or r d agent a owner agree toithe conditions stated on this form
SIGNAT
JRE TITLE t,r DATE
Proposal
woroved with the following conditions:
rement of any Town Permit, if applUble.
1. Proc
2. Subn
lsslon of as built repair sketch in duplicate (showing:
a. 0
vner's name
b. S
e Street Name, Town and Tax Map number
c. L
cation of installed components tied to twoIxed points
d. S
stem description (e.g., 1250 gal. Concrete aseptic tank, etc.) .
e. I
tallers' name and phone number
3, System
repair to be performed in accordance with the
2bov,,
proposal and conditions.
Proposa
Approved Propossil Denied
I ct
's igna re Title Date
COPIE
White (PCHD); Yellow (Town BI)j Pink (Installer). Orange (Applicant)
PC -RP
9ML
Rev. 8/
NOU -1 -2886 klED I.J.::_ "A TEL:845- 278 -7' 81 NAh1E:PUTNAM COUNTY DEPARTMENT OF P. 2