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BOX 10
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
lP
SITE LOCATION � 1 / /PiJ
OWNER'S NAME
MAILING AI -ISS
OFFICIAL USE ONLY
- X369-0
TM# 01
PHONE
PERSON INTERVIEWED .---D �� !� PCHD Complaint #.
Name & RelationaMp i.e., owner, tenant, etc.
DATE /// z //G _� TYPE FACILITY
PROPOSED
ADDRESS
-�-, �-�— PHONE.
IV
REGISTRATION# Y f dyl
Proposal (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.
1, as owner, or reported agent of owner agree to the conditions stated on ttustorm. -
SIGNATURE
TITLE- TITLE-
Proposa opuroved 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
DATE
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, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
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1Z 1
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Inspector's Signature & Title A
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
I-acknowledge ecetpt =o €this ieport: SIGNATURE;
02/96 Title,