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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
YO Internal Use Only
epair Permit issued in last 5 years VDaIegated
in Watershed
kepair within Boyd's Comers, W. Branch or Croton Falls Res.
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Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review
OWNER'S NAME j—UNJU0%0 ,fG
MAILING ADDRESS 3 S 1 eS r
APPLICANT Ffe '' "J?4^v 4
Name & Relationship (i.e., owner, tenant,
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HONE # t% - 7Y -
DATE " i 7 ao FACILITY TYPE 5�d IV , (L CHD COMPLAINT #
PROPOSED INSTALLER reed .4*7,.,s PHONE #
ADDRESS �I� �`,' dZ }31 ^jp$ JO. y I � 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) p We-ZI
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 li professional
en�jsneer Qr registered ar hitect. / ,�,,^ ,
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I, as owner, or reported agent of owner agree to the conditions stated on this form 0/-
SIGNATURE f TITLE C04ra� DATE %
Proposal approved with the following 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 in accordance with the
above proposal and conditions.
Proposal Approved f Proposal Denied
Inspector's Signature & Title Dat
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML -
Rev. 8/05
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F *LADAMS, INC.
610 Route 292
Holmes, N.Y. 12531
'(845- 855 -3733)
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