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SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
V Internal Use 'Only PERMIT #R u
epair Permit issued in last 5 years ❑ of in Watershed ^V
Repair within Boyd's Corners, W. Branch or Croton Falls Res. Delegated `f
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review i
OWNER'S NAME
MAILING ADDRESS
APPLICANT
TOWN
TM# %'3, — / —V
Name & Relationship (i.e., owner, tenant, contractor)
DATE ( kO42 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER Li' ' PHONE # �A
ADDRESS / �� ' j REGISTRATION /LICENSE #
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 system) -
NOTE: The Department may require submittal of proposal from licensed professional depending on the _
nature and extsnt of the
%- AX u
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner)
I, the septic installer, agr o c it the conditions of this. permit for the septic system repair
SIGNATURE TITLE -° DATE 'T">
(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.
Proposal Approved
s Signature & Title
Repair proposal is in compliance with
INTERNAL USE ONLY
Proposal Denied
le codes
01
a.-t a.
Da
Yes
V-1 o'
OratioK Date
No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Ara
t a
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE
All information below must be fully completed prior to an'y scheduling
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
A
PROPOSED CONTRACTOR /INSTALLER VL�%,�%cSPr� %C PHONE #j�
ADDRESS L / - Mct� o REGISTRATION /LICENSE #
Reason for exaloration:
❑ failure to surface ❑ back -up in house ❑ find limits of system for repair ❑ other (explain below)
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FOR COUNTY USE ONLY
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Date
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Title Date
�L Time: 3 O
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