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IMAGING & MICROFILM ACCESS, INC.
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BOX 11
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INN
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61 L I
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01118
SITE LOCATION L
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLYY r�
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PHONE � Kq�-- .2-7Y-
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PERSON INTERVIEWED PCHD Complaint #
/ Name & Relationshin ft e., owner, tenant, etc. /
DATE ?2� [ -Z / 0 3 TYPE FACILITY j e, / edlc e.
PROPOSED INSTALLER.
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ADDRESS O fu Ll_ (( Rd P,0 S- ' /U y REGISTRATION# % 3
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.
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I; as- owner, or reported -agent of owner agree to the conditions stated on this farm:
SIGNATURE TITLE 09:i1 , DATE /2- 0 �_.v
Proposal ved wifi&e 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.
Proposal approved '
Inspectors Signature & Title D E
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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