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00610
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00610
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PUTNAM COUNTY HEALTH DEPARTMENT
0!4 DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES N01z Internal Use Only PERMfr #
❑ 1.Z1 Repair Permit issued in last 5 years ❑,Not in,Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. & Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION' �a - J _ s: TOWN .19, =,q (_ -- TM #
OWNER'S NAME , PHONE # Q
MAILING ADDRESS %., l A&.94',m as A'�'4. !;-- Gy�'� t T�SDi'i /V /�•9 G �
APPLICANT'`
Name & Rel nship (i.e., o )r, tenant, contractor)
DATE 2, FACILITY TYPE `S . PCHD COMPLAINT # car
PROPOSED INSTALLER PHONE #_ �,�71�%
ADDRESS �'_EGISTRATION /LICENSE # I1C4
Proposal (include a se 48,te 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
nah ira and axtant of tha ranair
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner)
I, the septic installer, agree �to- comply with a conditions of this permit for the septic system repair
SIGNATURE TITLE DATE '
(installer)
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 36 days of the repair, In duplicate showirp:
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 ❑
z ;z1 �a
In' oector's Sianature & Title Ex6irationDate
is in comDliance with aDplicable codes Yes
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
To: Page 2 of 2
2012-09-2109:24:35 EDT 19144623759 From: Baker Properties
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
XM
h2
Internal Use Only
PERMIT ltr
❑
❑
Repair Permit issued In last 5 years
❑ Not in Watershed
❑
U
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
0 Delegated
❑
❑
Repair within 200 ft. or a watercourse or DEC-mapped wetland
❑ Joint Review
SITE LOCATION 1 fncr(ho+rw',;' 3 t2 . TOWN R � Y1 TM It
OWNER'S NAME PHONE # o?D -_ool`AO \b MAILING ADDRESS
APPLICANT
Name & Relationship (i.e., owner, tenant, eonftdor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER PHONE #
ADDRESS REGISTRATION /LICENSE #
Pro al (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.
I, as owner,agr to the conditions stated on this form
/r-
SIGNATURE, TITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE TITLE DATE
(Installer)
Proposal aoixoved with the following conditions:
1. Procurement of any Town Permit, it applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair. In duplicate showirt.
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. Systern description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed In acoordance 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 corn liance with applicable codes Yes O No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
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EXCAVATING CONTRACTORS
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