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04067
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
F'U, I . a � % �, {
SITE LOCATION 90 Zm4rr D c t% TM# 93 ; 6 6 . 7
OWNER'S NAME a N*90 PHONE &Y,5-
MAILING ADDRESS K:S'� C , M i o,S
PERSON INTERVIEWED PCHD Complaint #
_ ame Relationship i.e., owner, tenant, etc.
DATE ! I I y I ( TYPE FACILITY �f ,
PROPOSED INSTALL HONE $ k,(S — 6726.
ADDRESS,* 654;�Wi4�Nl�' A " 0 -r- if WRI V4 c'c.!F 1 REGISTRATION# P C• ).3q
1C J
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.
Q k e z
I, as. owner, or re orted went of owner agree to the. conditions .,stated.on.this.form.
SIGNATURE � - -- - - - TITLE � A " 6 Or,,*' T'...... _ ...... -DATE I .,�
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 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 99NE
DATE
DIVISION OF HERLTH S&WICES f
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
Is NAM qR_ inns Cd t�.
SITE UXXTION 96 Lewe p (Lt vc- tic
AAR,YTMiG ADMES tA-KM- f' rz kA 14 f M, -f 2
PERSON .INTERV EWED PM Canplaint
Name & Relationship (ice, owner,tenant, etc.)
DATE , TYPE FACILITY
PHONE 9-7—C –,-) S7 r
REGISTRATION # rAl z�
Pro (include sketch locating all adjacent wells):
WTEs Repair must be in same location and of same type as original sewage disposal syst n.
Different location may require submittal of proposal from licensed professional engines or
registered architect.
"&r . %CZ;0 f'-(p-
r c5� :r
a
-,,_i -k. --I- 1 7 A 11 ,.
Proposal app 9 Proposal Disapproved
�f
Inspector's Signature & Title T
Proposal approved with the following conditions:
la Procurement of any Town permit, if applicable.
20 Submission of as built repair sketch in duplicate showings
ao Owner Is name.
b. Site Street lame, Town and Tax Map number.
c. Location of installed components tied to two fined points (eogo,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 owner,,,Ir reported agent of owner agree to the above conditions.
SIGNATURE TITM D. / Q C,
.M.- ftte MCED) ® Yellw (Tam HE); Pink (Applicant) -- -'m