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PUTNAM COUNTY HEALTH DEPARTMENT,
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR (,
]/ Internal Use Only
1
❑ 6JI Repair Permit issued in last 5 years of in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. [��/Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wet/ 2nd k Joint Review
SITE LOCATION ' G TM # a3 . 53
OWNER'S NAME j. o f- I-A ;, r PHONE J Q
MAILING ADDRESS •j?,4p, ir eh Al L/
APPLICANT I VJ 4t "G . `
Name & elationship i.e., owner, tenan , contractor)
DATE_ FACILITY TYPE'. PCHD COMPLAINT #
PROPOSED INSTALLER S Su /1, . v PHONE#
ADDRESS v ) REGISTRATION /LICENSE #
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 trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATUR TITLE
Proposal approved with the f wing conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed Zinac rda nce with the
above proposal and condition
Proposal 9pproved Proposal Denied
4 p
Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
DATE y��o
Sheet _of_�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
Street Town
PERSON IN CHARGE
Zip
Name and Title
TYPE OF FACILITY:-tea
FINDINGS:
Signature and Title
R,Fpn'RT TT CF.TVT'T) "RY:
I acknowledge receipt of this report: SIGNATURE;
02/96
Title:
9
O
Luaro
April 2007 300 Mcmanus Rd North
new 1,000 gal tank
Patterson NY
Tax map# 23.6 -1 -33
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SEPT /C SYSTEMS..WCL
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EXCAVATING CONTRACTORS
845 - 70 -8800
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