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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
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OWNER'S NAME 19 :i.5 'n �/��� �r �n ck PHONE
SITE LOCATION r°r��ner ��� 14f U� :u (�lc� .-- S`7'r�ec: 7`s SA/- 6 —a,2
.NAILING ADDRESS �{ %%%� u / 7 7`c: i' i l e- Pa '. '�h d sh f,`: -` _ L ,f% / D3 7 2
PERSON INTERVIE{aEED fit: s/ un &,e&t -t., ej ajl7 e,r- PM Ca plaint # .
Namb & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER ,` Ci• 7 PHONE S Ak " 317
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. n
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Proposal approved Proposal Disapproved
Inspector's Signature itl
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roposal appraved 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 canponents tied to two fixed points (e.g. house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diem. x 6' 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.owner, or reported agent of owner agree to the above conditions,.
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]P1ES' : Vbibe (PQD); YeUcw ('ibhn ED; Pink Ggliant)