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BOX 12
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01238
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION P— Z TM#
OWNER'S NAME j57C PHONE
MAILING ADDRESS 4:P4 P Ie Jl�Soa
13 L ei l/'D'l an
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY . lees --
PROPOSED (NSTALER_ :7<- - PHONE
ADDRESS .9 7w 6r� �� �q�IyYREGISTRATION#
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.
I, as owner, or r ported yen tf wner agree to the conditions stated on this form.
SIGNATURE mil$ TITLE /SAC- DATE
Troposal loproved 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
Inspector's Signature & Title /DAT9"'
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML