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BOX 25
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PUTNAM COUNTY HEALTH DEPARTMENT _
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OWNER'S NAME l - -�' •' ?° /� `� `� PHONE
/f - 343 `6 9v
SITE LOCATION �v �� �`j�ir � L-- 710
MAILING ADDRESS S Ca G• �-�
PERSON INTERVIEWED PCHD Complaint #
& Relationship (i.e, owner,tenant, etc.)
DATE 9 TYPE FACILITY
PROPOSID TAKER /� !7 ti°_ v�/ r PHONE
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 suhni.ttal of proposal fram licensed professional engineer or
registered architect.
Proposal approved
Inspector's Signature
Proposal Disapproved
roDosal amroved 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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x 6' deep
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 01 / c. ,+B c �' P /�` TITLE .L�7 S/ = DATE
XW: White MD); YeUc�w MyAn ED; Pink (Applicant)
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OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
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PUI'NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
A. E) M-r
00-660,11D 4Z �� V.1 0 1A D1
1) C114--k-0 PHONE Y-1 tt-,,�'7
i y- : n141L v N- C L-e V rQ
PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
uJ. RIK rr,-/4..r PHONE !,-24
REGISTRATION # 0
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.
m
Proposal appr Proposal Disapproved
Inspector's Signature & Title Date
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' diem. 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.
SIGNATt)RE - - TITLE_..
DIES: Hhite (PCfD); Yellow (3ai EU; Pink (Pppliar t)