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BOX 11
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
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SITE LOCATION �i/ riu'An7 �� (r o- a..i:Tl.�i�.�nl TM #�
OWNER'S NAME��,e C CS 9i- cl ' jdA I 6 E9,94 1) I PHONE _ � -7 A 6 ,�Z 6 e7
MAILING ADDRESS I--,A) L ioti it A) /i
PERSON INTERVIEWED PCHD Complaint #,
Name & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED PROPOSED INSTALLE Od d 4 c� nn l ' 6 c)(91 - UJA XJHONE -
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ADDRESS 0 41 6:6i r AL P.4 7f-r= 4.l',,. J a14 j a.�4REGISTRATION#
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.
C, t,J / I)i) O 4 A /
owner, 'or r `orted agent'of owner agree 'to the conditions stated 'on this fortri. °
SIGNATURE TITLE I�WAJC--e— DATE -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 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_ ��--
1
Inspector's Signature & Title TE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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