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BOX 12
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01262
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS_
OFFICIAL USE ONLY
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PHONE Z7A - S36c-
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER S ,St' 1 �t ,�, , PHONE Z 7`d � 0��
ADDRESS A 6v 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.
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-J, -7 -ov.meri or reported Mg nt of ^-w. ner agree to the conditions stated or. this fern.:.-
SIGNATURE TITLE &21= DATE 7-,fja -
Proposal 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' 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
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
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