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BOX 12
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IN 06
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01214
SITE LOCATION
OWNER'S NAN
MAILING ADDR
PUTNAM COUNTY HEALTH_ DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL_ FOR SEWAGE DISPOSAL_ SYSTEM REPAIR
OFFICIAL USE ONLY
A l f of *ees an TM# y1s c 1-117 '411
k, +Tens r PHONE 9l H AN) -31n5 `
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY ,3
PROPOSED INSTALLER_
ADDRESS
REGISTRATION#
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.
as owner,: r p rted.aent.of o►rter.ae.to.th? co�+ditio!+�s stated on this form...'.
SIGNA TITLE DATE
Proposal BDnroved 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 naive
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 G deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
DATE
A�
0
'Date_. Mart L ..... . . ....... ............. .....................
V 7 77'
,
UAM C* U T".1Y.",
PUPTN" "M; Mil Y.
i.
A lSewa
InstalMon 6T
e is.posal,.
Facilities
ppi or
i ' }'i , }" Fe
,-
'of 147;5 cc
The undersigned ebyl
makes application f6F ap certificate ;i
W proval of and "a cert
for the installation of S t
et
a;7�� C#s*ipool E] Chemical I
Toilet ff Privy E]
property
on the prop.
dekribed- below.
Location of Property
- Y ?.1
........
tt
-5 _19,1:AV
Villages
Subdivision,, ....................... ;
.... ...........
ock No.
Character of building! Dweilinj"�`�'
No. of Occupants_ B6drooms..'.%;V-' ........ :taihs'... ........... tx b�'
...... . ......
Garbage Disposal Sink ...... ........... z ............... ..... Automatic Laundry Washo .
-'Source of Water Supply !Public ❑ D; I)p
filled Well] Dug Well.❑
Name of Owner ........... Address .........
Diagram showh4g, l4cation of proposed''installation on property.
adjoining property line and distance from nearest water, watercourse or I
within 200 feet.-Also sho location of dv�ening,,.- or building to be seiied)±.
CA
Tank
77w 7
Q
7 ?:
io:-pe; r�di
Corrections, If .any, to be m4d
e,
-74;
"M 6 u bee oZt ..............
inspector
General Contractor_
f J i i y'.., j
Address ....... : .L..
I certify that I ha"'in'sp6cted the facilities Called ior, in the foie
same are installed Ns shown In the ftgrwi there'on with the ch
comply with the'se*age 'regulations of theTbwu Board of Heall
hereby grant this CERTIFICATE OF 00C1VPANCY.
Premises were Inspected on� ihe! fohowlng dates
Fir-at ......... ....... X::� .......................... ..... Date Issued
is
Lastl, ...... .......... ........ . .........................
Other! , .............................. ............. ............... V-
oi
Showeraiii, ...... ..........
❑ "' round[]
of wfter supply,
hi. appllatl- AI "d find tha
;es noted, and find that the#p ,z_xie14,'
of the Town of tPatterson
.......... ) ......
11.io
............. f .................
.............
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