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03017
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
SITE LOCATION 9� CeM R L.U"S TM# 69,09 r( i 7
OWNER'S NAME s7wg99-14 ' a.SS PHONE
MAILING ADDRESS '4 L LFc fi f 4 7
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc. "
DATE ®"� + TYPE FACILITY IQ 1
PROPOSED INS ALLERE4'"✓� (DP -6-( PHONE
ADDRESS,° � 65�, & M#PAV►4 LLF-y REGISTRATION #? Q— OF
Proposal (include sketch locating all adjacent wells): IYt,- /0,0f,
,
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submitqLaf proposal from licensed professional engineer or registered architect.
G C I f—h G *66 TA'git W i -rH
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i; as owl-ier - r a eported,�_of OVV,7ier agree-to `��e colidlti'6ris 'stated--orr th -
SIGNA w" TITLE 14 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 performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
6117102-
ZATE