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02543
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02543
PUTNAM COUNTY HEALTH DEPARBUM
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 - 3838/225- 3833/225 -3641
PROPOS.AL - FOR- SEYMM -DISPOSAL sYSTEm I'�P`' AIR
OWNERS NAME 5 Vi L oss PHONE
SITE LOCATION TK#
MAILING ADDRESS 6 b5- 0 Sr-o-, LvA vl a— �&.
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE (� (� �% TYPE FACILITY
PROPOSED INSTALLER 76W N G- t 16 e--R T PHONE
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.
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Proposal a roved jC
Inspector's Signature & Tit]
Proposal Disapproved
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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 cccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' dieum. 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, reported agent of owner agree to the above conditions.
SIGNATURE Ob f GNATCTRE TITLE Ll?,TE j
PIES: White MD); YeUcw (Tam BI); Pink (Applicant)
NOW OR
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