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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION o k
OWNER'S NAME
MAILING ADDRESS
0
OFFICIAL USE ONLY
TM# 5 �` Z
PHONE Z.Z,S-
PERSON INTERVIEWED PCHD Complaint #,//�c.l
Name & MeTa—tionship (i.e., owner, tenant, etc.
DATE 312- TYPE FACILITY Z �:e -
PROPOSED INSTALLER rZIAY� /���1J /� Sc� c .,-►s SHONE $"y5'� 79� q
ADDRESS -24 ��,i/�i" / /��c�_%'o%s r7 l N61 __ GISTRATION #�3
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 rep rted agent offer agree fo the conditions stated on this form: `
SIGNATURE /
TIME-
ro sal approve wiffie followiniz 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.
DATE .� O
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
� a
a
Inspector's Signature & Title D TE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
March 2004
:,;Plastic 1,000 gal
;septic tank
is
Valine
708 Fair St
Carmel NY
Tax map# 34-2-5
LI
Permit # R048-04
AAAILL
SAWCAP Foam
EXCAVATIMS CONTRACTORS
840 2 79