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Sheet _of�_
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL IIEATLH SERVICES
FIELD ACTIVITY REPORT
AT)T)R ES, 4 COZ AJ47.461, 111[ C 77W, SPA)
Street Town State Zip
PERSON IN CHARGE
Name and Title `
TYPE OF FACILITY:
Signature and Title
RFP()RT RF['.FTVF.T) RY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title;
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES qr
YES NO Internal Use Only PERMIT #�
Repair Permit issued in last 5 years tin Watershed
Repair within Boyd's Corners, W. Branch or Croton Falls Res. '� Delegated
* * Repair within 200 ft. of a watercourse or DEC - mapped wetland * Joint Review
SITE LOCATION .... TOWN P ' "p/t) T
OWNER'S NAME � \ " PHO�N/E #
MAILING ADDRESS _�Z/6 tj Lo e-11 gala k\ } t \ Gf
APPLICANT S i� rtn (- S ( (�/l �/C� i�ix�• A.�l'�
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Name a meiauonsnip ki.e., owner, tenant, contractur)
DATE (D O FACILITY TYPE /�-z"s (!G to, ��� I PCHD COMPLAINT # ,!
PROPOSED INSTALLER eS;��,IS I•rC�✓tGgC/►�}P/t� �cJictS PHONE# ' VaS5-I�SA6Ce-
ADDRESS
REGISTRATION /LICENSE # //,30
Proposal (include a separates etch ocating 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.
I, as owner,agree to the conditions stated on Ois form
SATURE, _ �,�. w TITL
IGN E
r tr
(owner)
I, the septic installer, par ee t ly with he conditions of this permit for the septic system repair
SIGNATU TLE �� DATE � G
(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
Proposal Approved <_ Proposal Denied <_
nspector's Signature &. Title Dat Expir tion Date
Repair proposal is in compliance with applicable codes Yes 5 No <_
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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