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PUTNAM COUNTY HEALTH DEPARDWT
DIVISION OF ENVIF0941WAL HEALTH, SERVICES
225-03,10
OWNER'S NAM
SITE 1=TI01
PHONE S 6 2I) 7Z.
TO
MAILING ADDRESS
PERSON INTERVIEWED PM Caq)laint #
Nam & Relationship (i.e,, owner,,tenant,, etc.)
DATE TYPE FACILITY fir; 'jam
PROPOSED INSTAUM 1�0 ... 6L PHONE
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 fran licensed professional engineer or
registered architect.
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Proposal a roved
s Signature &
Proposal Disapproved
/bate
voposal 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, Tbwn and Tax Map number.
c. location of installed capponents tied to two fixed points (e.g. ,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 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 ownerr, r repo [en of owner agree to the above conditions.
SIGNATURE A� TITLE )f, Jj e41A �NfVr DATE Zj
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Approved as noted
applioable Rules and Reulatioas oY the
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Putnam County Health Dpartment.
SPRUCE KNOLLS
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SEPTIC RE ;AIR PLAN
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Frederick A. Zenz
7/25
292 Main St.
68 SPRUCE KNq�LS
Nelsonville, N.Y. 10516
TOWN OF PUTNA :VALLEY SCAL!
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