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BOX 23
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PUTNAM COUNTY HEALTH DEPARn4ENT 7
DIVISION OF ENVIRONMENTAL HEALTH SERVICES i
O6*=' S NAME t Nk. a
No FL (L2 t9 t- e.-`tq-
PHONE
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SITE LOCATION t qI C
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MAILING ADDRESS
V A, L LF V N S 0 .4�-'12
PERSON INTERVIEWED
PCHD Complaint #
Name & Relationship (i.e, owner,tenant,
etc.)
DATE j G' _�
TYPE
FACILITY
PROPOSED INSTALLER
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PHONE
_T2 to —Q Sir
REGISTRATION # % -
Pro (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 approved Proposal Disapproved
Inspector's Signature & Title
Dife
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.,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 a TITLE iL' o c,4 r DATE
OOP'IES: Mite (MD); Yellow (Tam ED; Pink (AFpti,cant)