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BOX 18
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NMI liff IN
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OWNER'S NAME �/i',Q/i/y �,$�C/ri%iV/3�'!ffA- /�fP PHONE # S�Ilr- 27P -0 I-r
MAILING ADDRESS V/ LAAio DAP. ,s X - ,y
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE Z Ale 6 FACILITY TYPE g OS,. PCHD COMPLAINT #
PROPOSED INSTALLER YNV.4U_SLsI°/'ICS�%STC�i[�LS .Li1lL PHONE # F4(S',.27q-ff-j25!
ADDRESS 2.piU�/�%LLRI�_, iPG�Gt/J- Zf REGISTRATION /LICENSE #93
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE TITLE �
Proposal apmoved with the followi 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
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditions. /
Proposal Approved ✓ Proposal Denied _
5 � 0
Inspector's Sign-atUP9 & Title Dat
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
DATE
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1,000 gal plastic septic tank
ex. drywell pit
Distribution box
ex. the field
TYMAU SEPTIC SYSTEMS, INC.
14> Ivy Hill Road
BRIMSTER, NEW YORK 10509
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IX