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SEP -18 -2002 09:48 FROM MR. ROOTER PLUMBING TO 2797921 P.02
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OWNER'S
MAILING
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES--
OWXVI USE ONLY
PERSON INTERVIEWED PCHD Complaint #
Me X KelabODS14 .e., &mef, Temi,
DATE TYPE FACILWI CS0 &4tf
PROPOSED INSTALLER .,M.� �� PHONE . (P'K 2J 01—
ADDRESS VIQ 1 I REGISTRATION#
p (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
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I;,as owner, o rted t er agree to the conditions stated on this form.
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SIGN E AIVR T4TLF_�
B=mal approved with the fQ lowing ma 'tiom
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 (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, tbree precast & diam. X 6 deep
C. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
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Inspector's Signature & Title
CQPM& White (POW); Yellow (Town BI); Pink (applicant)
MAP 99ML
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SEP -19 -2002 09:48 FROM MR. ROOTER PLUMBING TO 2797921 P.01
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