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BOX 11
01054
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01054
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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SITE LOCATION
OWNER'S NAME Y C.CY*- PHONE
MAILING ADDRESS 1 t 'R ko A/ Co
OFFICIAL USE ONLY
PERSON INTERVIEWED C PCHD Complaint #
anle a0elationship i.e., owner, tenant, etc.
DATE 0 q TYPE FACILITY
PROPOSED INSTALLER PHONE F qS - n? - 7S5
ADDRESS a �;�, �b Cs�- . P �� LLD REGISTRATION#
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.
I, as owner, or repo agent o wner agree to the conditions stated on this form.
SIGNATURE TITLE �rG� DATE --%Z5' 0
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 (e.g.,house corners).
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.
Proposalapproved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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