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BOX 28
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03602
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION 0, F ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION
4)L4 �iX`
OWNER'S NAME JL
OFFICIAL USE ONLY
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MAILING ADDRESS ?.;I FFrK D%- Pty�.—I t� IL AIX /05
PERSON INTERVIEWED &� C e PCHD Complaint #
e e attons Ip (i.e., owner, tenant, etc.
DATE 7 �� TYPE FACILITY 57mile
PROPOSED INSTALLER ,Sail -:7:A c . PHONE 7
ADDRESS AD k�aic 1� y. /CW+" / REGISTRATION# he G 4e 1060
Proms (include sketch locating all adjacent wells): C�' � � ' QQ -sul5-
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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° T, as� owner, or rep- led agent of o er agree46 file conditions stated on this orm.
SIGNATURE ✓ TITLE Z/—C-
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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
DATE 7 .?- .
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
/U
DATE
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