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BOX 15
01597
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OWNER'S NAME
SITE LOCATION
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PUTNAM COUNTY HEALTH DEPARTHM
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PCEID Cauplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY lZc-T ,
PROPOSED INSTALLER A z'e et.; -aim _ .. ytl PHONE �P • &6 q
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.
6 C /G1
Inspector's Signature & Title
Proposal Disapproved
3.
cate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components 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.
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(e.g.,house corners).
three precast 6' diam. x 6' deep
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 ,.0 �� TITLE
mss: Vihite (MD); Yellow (23pn BI); Pink ftpUavit)
PC -RP 97
DATE 12-% -'7-1-7 % ?-° `-7
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