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BOX 28
03599
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03599
OWNER'S NAME,
SITE UXATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.. - 'FROPOSAI; FM: SEWAGE - DISF tYSTW- REPAiR
f S PHONE
PERSON INTERVIEWED / Pa D Complaint #
Name & Relationship (.e, owner,tenant, etc.)
DATE TYPE FACILITY Q
PROPOSED INSTALLER -%�L/i /f . 5407iK �' PHONE zez a " UW1
REGISTRATION #
Pro (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. kle
Proposal approved Proposal Disapproved
Inspector's Signature & Title OtA3
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' 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 reWrted agent owner agree to the above conditions.
SIGNATURE 0&4e ..y TITLE DATE
PINTS: W-dte (K D); Yellow (vi HI); Pink (Anl act)
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666666 PU NAM COUNTY HEALTH 8JG1Cela\s6JCLLa1
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
.... . .......: PRSAL;:FO SEWAGE,- DISPOSAL SYSTEK- REPAIR
SITE LOMTIO
MAILING ADDRESS
PHONE fa V — 09. a -'C-
TO 63-2-17
PERSON INTERVIEWED \3 PCHD Complaint # M
Rime & Relationship (i.e, owner,tenant, etc.)
DATE. -
L � 2 n _ TYPE FACILITY
.. 11 OR,,(
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.
�- d y'"r'�• � i� � /` * � /ice �-� �S ; / �' ��3
M
Proposal approved
Proposal Disapproved
Inspector's 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.
co Location of installed components tied to two fixed points (eogo,house corners).
do System description (e.g., 1250 gale concrete septic tank, three precast 61 diamo x 61 deep
drywells surrounded by one foot + gravel).'
e. Installer °s name and numbers
3. System repair to be performed in accordance with the above proposal and.conditionso
I, as owner,•or reported agent of owner agree to the above conditions.
SIGNATURE - TITLE 7 931' DATE
MESe Mite MID); YeUav CR7nn ffi) g Pink (Apptiamt)
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