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BOX 17
01904
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PUTNAM COUNTY HEALTH DEPAIZIMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225-0310
OWNER I S NAME �� Ll rT ✓J S rj-� , � �% PA
SITE IACATION -:5 :� y'.7 1 -, ✓� J� L /y To
MAILING ADDRESS
DATE
Name &
G- 6e
.e, owner,
PCHD_Q ik aint
ant, etc.)
TYPE FACILITY
PROPOSED INSTALLER - - PHONE
1
_(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.
J
Proposal approved _ Proposal Disapproved
DatA
Inspector's Signature & Title
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.,hoise corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' &am. x 6' deep
drywells 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.
3IGNATURE -/11 /r/ ✓l �`' i aL5 TITLE
-MS: V&be (MD); YeUcw MT n ED; Pink (Applicant)
C3
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225-0310
SYSTEM _.P
oKWMIS NAME ' ��r��� 5 • . ` � PHONE A
SITE LOCATION
MAILING ADDRESS
DATE
IRAZI
Name &
/_ ew
PCEID,lai_nt
p (i.e, owner,tenant, etc.)
ii TYPE FACILITY
PHONE � ;:�;*'T ^ <::� 7-:>- 5�1
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 sulmittal of proposal fran licensed professional engineer or
registered architect.
-elf r d, v --r
Proposal approved �%� Proposal Disapproved
,-
Inspector's Signature & Title o — Da
ItA
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
drywells 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 ✓l �`� /i t.L_5 TITLE -DATE
G;PM: trite (PCFD); Yellow Mkin HE); Pink (Applicant)
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