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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
Internal Use Onl
Repair Permit issued in last 5 years
.Repair within Boyd's Corners, W. Branch or Croton Falls Res.
Repair within 200 ft. of a watercourse or DEC - mapped wetland
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APPLICANT -�'�C I -�f I -C
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[Name & Relationship (i.e., owner, tenant, contractor)
DATE 7 12 FACILITY TYPE
PROPOSED INSTALLER //��
ADDRESS %�o-,( \941Z if
PERMIT #
U Not in Watershed
O Delegated
❑ Joint Review
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PHONI Ws
PCHD COMPLAINT #
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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 extent of the repair. -
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I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this. permit for the septic system repair
SIGNAT TITLE -� DATE
(instal
Pro os the followi c (47t, on-s--:
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
Proposal Approved ❑ Proposal Denied ❑
Inspector's Signature & Title . Date Expiration Date
Repair proposal is in compliance with applicable codes Yes ❑ No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
° - PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Internal Use Only PERMIT # F�)—
X Repair Permit issued in last 5 years LJ Not in Watershed
Repair within Boyd's Corners, W. Branch or Croton Falls Res. A Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
3 / iOWN
Name & Relationship (i.e., owner, tenant, contractor)
DATE 41b FACILITY TYPE
PROPOSED INSTALLERl�il�►��
ADDRESS
k/TM #/'�
PCHD COMPLAINT #
}x1EGISTRATION /LICENSE #
Proposal (include a separate sketch locating the houses, 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 extent of the repair.(---) _ / • ,¢..— , ____ , / _
Cam. �_elz r-r k
Po�eSz f1` .-hf -j i�LFJI�(�Clv��' {,r- CKnFirrJ.
1, a wner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this.permit for the septic system repair
SIGNATIJR � TITLE DATE
(installer)
Proposal approved with the folio In conditions:
1. Procurement of any Town Per it, if applicable.
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
5 completed SSTS repair will function.
) No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved 6�T_
pector's Signature & Title
is in compliance with
Proposal Denied ❑
Date
cable codes Yes
-7/'q_/0 )
Expiration Date
No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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