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BOX 12
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01208
PUTNAM COUNTY HEALTH DEPARMU V \ I q / Q'
._.. _- ---- L�NLHTC�T_- OE:..ENVI�AL_HEALTH SERVICES �ji l o
OWNER' S NAME Qn 4T 6
i 0,550
PHONE
(91V) r7Z - 9 'O;r
SITE IMTION
MAILING ADDRESS ry►e
PERSON INTERVIEWED an C� sS�' C`�vner. PCHD Canplaint # -----
Name & Relationship (i.e, owaer,tenant, etc:)
DATE --/l-f TYPE FACILITY ho144
PROPOSED INSTALLER �'� - PHONE 20 - -?S3- -33 -73
REGISTRATION # P. e- -s V 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.
/VC/0 C I /S.0 o �A lsS c,..
d i f 6 /i s e- (J /I c o -, tom
/J PdS io 3c 267e
Proposal approved Proposal Disapproved
Inspector's Signature & Title Date
roposal 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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE �TASA114r, DATE
Q0P16: White WID); YeUcw (fin HI); Pink (Agliamt)
PUTNAM COUWY HEALTH DEPARTMENT
_ .. - _.rDDI ISIO_N CAF- HEALTH SE (_M. -
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
aem °S NAM A Al Je e'o 4 Oo&-p—v
G-
SS
PHCM
SITE rmATioN !i l - FJ ��? bC� �( �'
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LJ-' Al.
6 N.0i —A64&#
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PM CcWUint �
Name & Relationship (ice, owner,tenant, etc.)
TYPE FACILITY
1
PHCHE 426 6 17 41(ld 24�a
REGISTRATION
Proposal (include sketch locating all adjacent wells):
$SATE: Repair must be in same location and of same type as original sewage dispowl system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
9V 3
1VP10
Proposal approved Proposal Disapproved
Inspector's Signature & Title Da
Proposal approved with the following conditions :.
to Procurement of any Town permit, if applicable.
20 Submission of as built repair sketch in duplicate showing:
ao Owner's name.
b, Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points (eogo,hcuse corners),
do System description (e.g., 1250 gal. concrete septic tank, three precast 61 disks. x 61 dup
drywells surrounded by one foot + gravel).
eo Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE
:
MAte MD) A, Yellcra (Tain ED; Pink (kpUamt)
TITLE
DATE