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BOX 11
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01157
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES-
OFFICIAL USE ONLY
SITE LOCATION �1 � �7� TM#
OWNER'S NAME 1 �� �, si��c a 1, 'ice �Z PHONE
MAILING ADDRESS. *--)A% 1.`1c,. s�•.a-�. ��ti ,�� wry ;•,t'�: -- a}a', �{ . 1 � � t�
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PERSON INTERVIEWED fi, -.,, 1,.r- PCHD Complaint # ;
Name & Kelationslup i.e., owner, tenant, etc.
DATE TYPE FACILITY
� N_t C) 5 ref. I r.r • P1,,z. " �t' yt
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PROPOSED INSTALLER PHONE i �1 ° ` c1s - -7 15 5
ADDRESS S " s �c� rtS�' '�� 4.�� N a� r,�; ��.1'. REGISTRATION#
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Proposal (include sketch locating all adjacent wells): 1 1 .
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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�r illldn t9 .� Ri/i. •t i - .
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as owner, or reported agent fj owner agree to the conditions stated on this form.
F SIGNATURE X44 E- 9 �V\ TITLE �A'"'`i f' DATE
mpo_ sal a proved 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.
Proposal approved
nspector's Signature & Title1TE
.OPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
'C -RP 99ML `"
PUTNAM COUNTY- HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL'.SYSTEM REPAIR
OFFICIAL USE ONLY
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SITE LOCATION ' Z SZ .� %•�orr° ;�2 TM#
OWNER'S NAME (' ?��e�A�t1 C���,L� PHONE
MAILING ADDRESS' S l'`c s4�,�, C� ��.,z �y;��ti., } '`�t ..
PERSON INTERVIEWED PCHD Complaint #
Name & Kelationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER Y ~�1 � v PHONE
ADDRESS a � W,,Y. REGISTRATION#
Proposal (include sketch locating all adjacent wells): w
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 reportedagent 6f1f owner agree to the conditions - stated on this forrin'
SIGNATURE '��� �.►QX TITLE ~� c
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.
Proposal approved A---.1
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE