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BOX 12
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
SITE LOCATION 71e, TM#
OWNER'S NAME e lgg!•�3 o PHONE
MAILING ADDRESS
40
PERSON INTERVIEWED .1 ::- - -.) -,0-? 6 PCHD Complaint # �- -
Name a lationsnip (Fe., owner, tenant, etc.)
DATE 0: ZV t 3A: TYPE FACILITY _3 ;5✓
PROPOSED INSTALLER 'PHONE
ADDRESS 3 6 Hlo, ), REGISTRATION# PG ��/
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.
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-Las--omner;ar-r- p-Orted-g-e -
ot ow-n-:er- agree t6-- the 'c6nditf6iff "st@ted on 'W's" form.
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SIGNATURE W TITLE DATE
Propo mved 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 Gdeep
e. Installers' name and number. 1
3. System repair to be performed in accordance with the above proposal and conditions.
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Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC-RP 99ML
ATE
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a Sheet of
PUTNA M COUNTY DEPARTMENT OF HEALTH
t� YOB` FIELDACTIVITY REPORT
NAiyx % ®2� TPl•
Street -Town--,' State Zip
PERSON IN CHARGE
OR TNTF-RVTP,
Name and: Title
TYPE OF FACILITY
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FINDINGS:
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