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BOX 7
00597
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00597
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
YES N Internal Use Only
❑ pair Permit issued in last 5 years
❑ . Repair within Boyd's Corners, W. Branch or Croton Falls Res.
El 11 Repair within 200 ft. of a watercourse or DEC -map w
SITE LOCATION iCj I �'I A m +6 Mev W MTOW N _
OWNER'S NAME �I.i7��1L. j ZX1
MAILING ADDRESS '> L H 1'7kr^r�✓1n M
APPLICANT
TEM
PERMIT # I-T W
❑ Not in Watershed
J- Delegated -•4&Ak oe (y
❑ Joint Review
TM# — I
PHONE # -aL11--3r —4TY0
107o - 61y.2
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INS ALLER r T�����t -�� PHONE # ��f S =�p�(7 ` &0Z qil
ADDRESS REGISTRATION /LICENSE #
Progosal (include a sepa ate 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. f r
I, as owner,agree to nditions stated on this form
SIGNATURE
tt TITLE 0L4jg_Z.a! DATE v
(owner)
I, the septic ins , ag o c ply with the conditions of this permit for the septic system rep r it
SIGNATUR TITLE &Q ' ' DATE 7 0
(installer)
ri vkUaai uWIJi vvvu mu I u is ivnUwn Iy wl wuwi w. 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. o completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Pr osal Ap d Proposal Denied ❑
I pector's Signature & Title Date Expir tion Date
Repair proposal is in compliance with applicable codes Yes O No
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
(Q! M656.6244
0
AS BUILT FOR -
ELIZABETH GHITZA
514 FARM TO MARKET ROAD
BREWSTER, N.Y. 10509 - 6142
BAKER
EXCAVA` ON INC
57 EAST VACATION DRIVE
WAPPINGER'S FALLS 12590
EMAIL @ BAKERSEPTIC@OPTONLINE.NET
Hc;us>=
ar-TI c TANK
/09
SEPTIC
INLET
OUTLET
TANK
A
9'
14'4"
B
42'
43'6"
BAKER
EXCAVA` ON INC
57 EAST VACATION DRIVE
WAPPINGER'S FALLS 12590
EMAIL @ BAKERSEPTIC@OPTONLINE.NET
Hc;us>=
ar-TI c TANK
/09
I
Sheet_ Of_L
PUTNAM[ COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT .
NAME, �r �,f I T P.I:
\
Street Town tate Zip
PERSON IN CHARGE
ng rNTF.RvTF. r) 9; .4- 0-*0
Name and Title
TYPE OF FACILITY
FINDINGS: v,j �� tC C 04 • ,�;� /,iL �,"�
Si rt e
$FPORT RFC'FTVFT) RV•
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
P017
(e,45)656-6244 SAKE R /09
AS BUILT FOR -
ELIZABETH GHITZA
514 FARM TO MARKET ROAD
BREWSTER, N.Y. 10509 - 6142
ExcAvA` iON INC.
57 EAST VACATION DRIVE
WAPPINGER'S FALLS 12590
EMAIL @ BAKERSEPTIC @OPTONLINE.NET
.,ELL
HOUSE
SEPTIC TANK
SEPTIC
INLET
OUTLET
TANK
A
9'
14'4"
B
42'
43'6"