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23.06 -1 -10
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
FY ES NO/
Internal Use I R
_ a On Iv PERMIT #
0
Li V / Repair Permit issued in last 5 years L1 Wot in Watershed
❑ epair within Boyd's Corners, W. Branch or Croton Falls Res. , 31 Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
4':.: SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
759'r io3 - Z
N me & Relationship (i.e., owner, tenant, contractor)
DATE l D FACILITY TYPPE �., , PCHD COMPLAINT # oA.
PROPOSED INSTALLER � 5� PHONE # 11'7 21 V�'J<6 3
ADDRESS 2 ,Grp/ ciy �. REGISTRATION /LICENSE # /022
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.
1 U - -
I, as owner,agree to th conditions stated on this form �ry
SIGNATURE TITLE DATE ,5! / b
(owner) i
I, the septic installer, a to co ith the conditions of this permit for the septic system repair� /
SIGNATURE TITLE DATE
(installer)
Proposal approved with the following conditions:
t . 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.
Approved
InsPbctor's`SiQn-ddture & Title
Is In compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
INTERNAL USE ONLY
Proposal Denied ❑
D to
_ rG
)pllcable codes Yes ❑
Expirat on Date
No
Rev. 2/07
n
i
AX G & M CONSTRUCTION
WNW— 1 175 E. Holmes Road
HOLMES, NEW YORK 12531
(914) 878 -4355
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MA G & M CONSTRUCTION
175 E. Holmes Road
HOLMES, NEW YORK 12531
(914) 878 -4355
G c, K
cvs0y, V -) 1Z.�3
man
/I`'- io
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
vac Nn i
Internal Use On
PERMIT # IC " 11 70
❑ Repair Permit issued in last 5 years Abt in Watershed
epair within Boyd's Corners, W. Branch or Croton Falls Res. legated
E3 Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review
-1":-.1' LOCATION C�b� TOWN IP44 TM #
:�, 'OWNER'S NAME if A PHONE # n91r x 3
MAILING ADDRESS rv< l
APPLICANT C <14
N me & Relationship (i.e., owner, tenant, contractor)
DATE l � FACILITY TYPE ; , PCHD COMPLAINT# )0/7
PROPOSED INSTALLER �rf''�o���y� PHONE #
ADDRESS L &;1 ACy REGISTRATION /LICENSE # _1.2
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.
I, as owner,agree to th ' conditions stated on this form 12/ SIGNATURE TITLEO�� DATE 5 b
(owner) i
I, the septic installer, a to co ith the conditions of this permit for the septic system repair
SIGNATURE �� TITLE DATE S
(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 npmber
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
Ins
& Title
is in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Proposal Denied
❑
n
Date
)olicable codes
Yes ❑
lvltd-,,
Expirat on Date
No Q�
Rev. 2/07
� •7
�'
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 any scheduling
SITE LOCATION 0 A 4 TOWN �✓{.� TM #
OWNER'S NAME 0 PHONE # 8� r�? 3 2q03
MAILING ADDRESS 1J 12,51
IV
PROPOSED CONTRACTOR /INSTALLER C i % lu�/5 k/k�i� PHONE # 1721 SvaV S,3
ADDRESS � Z�LeX!UY-REGISTRATION /LICENSE # f U
2�1 .
Re son for exploration:
failure to surface ❑ back -up in house ❑ find limits of system for repair ❑ other (explain below)
FOR COUNTY USE ONLY
Inspector's Signature & Title Date
Appointment Date: Tjme:l�
kly:excel:septic