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BOX 26
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03216
SITE LOCATION
OWNER'S
MAILING
NAM]
PUTNAM COUNTY HEALTH DEPARTMENT /
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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ADDRESS
. PHONE
OFFICIAL USE ONLY
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY w
PROPOSED INSTALLER HaW,40,0 94-,(fl E.A,,r PHONE 8 `fS- 7.� %/ 8". 6-
ADDRESS , ,+u 14 i v�_ �'' . 7�i '; f , 106,75 REGISTRATION# C. /
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 pr�o� rqm licensed professional engineer or registered architect.
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1; as owner, r reported a_g nt '6t-ow- 'n-e'r a ee to the conditions stated on
SI TITLE Ji
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 dame
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
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
4
,ors
Inspector's Signature & Title
COPIES: White (PC> ID); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
9�
DATE