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BOX 25
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION � O
OWNER'S NAME .cj. •
OMC,, U221L USE ONLY
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PHONE 5_2 T — 7 / V
MAILING ADDRESS
PERSON INTERVIEWED eyya/,/�C�r.�'� PCHD Complaint #
Nark KeTationslu ., owner, tenant, etc.
DATE / e / / /c
PROPOSED INST.
ADDRESS
TYPE FACILITY
G&a/� PHONE
REGISTRATION#
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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Leas owner. :rPparted.agent of:; mar:a b, -tc �e cgnd tions Sta
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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 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
40
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