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BOX 17
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION
OWNER'S NAMI
MAILING ADDRESS
010,rc vo"ATM#
PHONE
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OFFICIAL USE ONLY
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PERSON INTERVIEWED PCHD Complaint #
Name Relationship i.e., owner, tenant, etc.
DATE 9_10 -0 3 TYPE FACILITY
PROPOSED INNSTALLER I S�'A@TC, �f- AJ _, PHONE
ADDRESS PO REGISTRATION# L01 -
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 repo ed agent of owner agree to the conditions stated on this form.
SIGNATURE TITLEz DATE %' !tq 101
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
WA
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