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BOX 25
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02974
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
V* i
SITE LOCATION
OWNER'S NAME _
MAILING ADDRESS
OFFICIAL USE ONLY
-3 y
PERSON INTERVIEWED PCHD Complaint #
I I Name & Relationship i.e., owner, tenant, etc.
DATE
TYPE FACILITY E�-Y--
PROPOSED INSTALLER 6tto %� zt� PHONE �9- U
kDDRESS pu -t ih gyp+ 1 [, Afsy j :E 9i` REGISTRATION# Z( ! 3
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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.
JILM e e i c i9-c T 14- A- A61501 !6 T
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I, as owner, or eported_a ent of owner agree to the conditions stated on this form.
SIGNA TITLE rTG� /'�✓ 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 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 rformed in accordance with the above proposal and conditions.
Proposalapproved
pector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML