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BOX 15
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01588
OWNER'S NAME
SITE WCAXION
PUl'NAM CIOU TTY HEALTH DEPAR TRENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PHCNE
PERSON INTERVIEWED v PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY �u'" f77ltadt,y
PROPOSED INSTAL TM ffim
REGISTRATION # (Jt/
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.
/ � a _ lip � Lam. i►l �:
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2.
3.
s Signature & Title
Proposal Disapproved
�osal approved with the following conditions:
Procurement of any Town permit, if applicable.
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 camponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
Date
(e.g.,house corners).
three precast 6' diem. x 61 deep
System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or, repo agent of owner agree to the above conditions.
SIGNATURE TIME DATE
XW: *Ate MD); Yellow (23pin BE); Pink (kj li®nt)
PC -RP 97
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14
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION ALC
OWNER'S NAME
MAILING ADDRESS 12.
OFFICIAL USE ONLY
10 0 —0 a—
TM# 3M--2-9
2.9/
PHONE
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER �7�� -, PHONE AS— 2-?9q
ADDRESS 9 — �'��n� c c.� . b�,Qc a REGISTRATION# i ilcrl- 4 .
T
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.
/G�C/��,/- ��C�1�ro- tr:��aj �,.Q.�/F'/�y�..��.2�__C�'' /y1�i�t- -�,rL �-�f �.��d car,, �/� <�i►�t����
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J, as owner, or reported agent of owner agree to the conditions state_ d on this form.
SIGNA / AQ TITLE �lLe — DATE S r�" 2� z_
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 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
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
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