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BOX 12
01277
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01277
PUTNAM COUNTY HEALTH DEPARTME[dr
DIVISION OF ENVIRAL HEALTH SERVICES
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SITE IACATION
MAILING ADDRESS
PERSON IN'T'ERVIE
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DATE lfln. n(1� 1 110 TYPE FACILITY {�-�Un
PROPOSID INSTAUM PHONE ?/y- �-�e- 62_
REGISTRATION # PG x'31
Pro (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
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conditions.
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Proposal approved Proposal Disapproved
!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
drywalls 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 Qwr,��,
DATE
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