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BOX 11
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PU'INAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OFFICLAL USE ONLY
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PERSON INTERVIEWED PCHD Complaint #
L� ame attons p (I.e., owner, tenant, etc.
BATE �(� � TYPE FACYLITY� �
PROPOSED INST
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ADDRESS REGISTRATION #.
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Pr (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
ruay'require'submittal'of nroposal from licensed professional engineer or rregisterd architect.- -
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I, as owner,A reported agent o owner agree'to the conditions stated on this form. / '
SIGN A I7IE r'a�I�d� DATE Z2 U ,Q�J�
Proposal =Mved with the following conditions:
I . 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, three precast V diem. X 6 deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved-
Inspector's Signature & Title DA
COPIES: White (PCHD); Yellow (Town 131); Pink (applicant)
FAX
Date
Numbcr of pagcs including covcr slicct
P.01
ALL COUNTY RESOURCE MANAGE=ME=NT
BUILDING AND INSTALLATION DIVISION
JJ MAPLE GRANGE RD
vcrNON,NJ 074G2
From:
f�honc Phone 000 - 4213 -G1 GG
Fux Phone - ._ ._... _.......... rox Pholic 973- 764 -G404
CC:
For' you" i'uview 0 Roply ASAF, ❑ . l'I�:;isc: r.��nun<,iil
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99 Maple Grange Rd., Vernon, NJ 07462
1-800-428-6166
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SITE LOCH
OWNER'S
MAILING
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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PERSON INTERVIEWED . PCHD Complaint
J "01 1_ Name & Relationship i.e., owner, tenant, etc.
DATE
PROPOSED INST.
WAY
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TYPE FACILITY.
PHONE7L� ;
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
I, as er, or reported ag of wner agree to the co �tio stated on this form. l
S TITLE �L/ 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 (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.
Proposalapproved
Inspector's Signature & Title A
COPIES: White (PCIID); Yellow (Town Bl); Pink (applicant) _. ....... . _.- .— .. _ ......... . ..:._..... __............ _._._.. ......
_. .
PC -RP 99ML