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BOX 12
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0 1167
a PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OFFICIAL USE ONLY
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
TM# 3 7.,nw aC ,5e 6 o(— I — /
PHONE �2) - 60 '1:1
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER &, 1-ps e S �:` S P,�Iz e e- PHONE 1' 3r --31 6 3
ADDRESS REGISTRATION#
Proposal (include sketch locating all adjacent wells):
MOTE: Repair.must be in same location- and-of same--t)Te as ,original sewage disposal s -ystem :Different location -
may require submittal of proposal fromlicensed professional engineer or registered architect.
I, as owner, or reported ent of owner a e to the conditions stated on this form.
SIGNATURE TITLE QUl-'y1.[ n _ DATE 6///,
Proposal 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 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
COPIES: )Mfe"(PC1 ID); Yellow (To•wri BI); Pink (applicant)
PC -RP 99ML
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