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04191
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04191
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
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SITE LOCATION 3 / 7A4V4 ETs',r 7-Z e�-0 TM# 3, *n -- / —I ao
OWNER'S NAME K v-fa °r F le £ 1% 'T A--f PHONE 9l Y XV V 3 6 o
MAILING ADDRESS L.H- K'9 Tf- 9- K f k i t I / (9 -'Si- 7 y
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE nr? 30 0
PROPOSED ST,ALLER
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ADDRESS ,mot o% is
TYPE FACILITY 1<-fS -
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C 1: d•.l `i f �!` REGISTRATION# PC / 8'
0 0 (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.
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d-af owner °agree to *lie °conditions stated on'thisyform:
TITLE 46. <'ou "ir— DATE ,� /0-S,
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 corners).
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 ormed in accordance with the above proposal and conditions.
Proposal approved
pector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
DATE
HOWARD GRAGERT
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...: __ .296.05LE1WANA LACE RD:
:.._ iP.JJTNAM VALLEY,_.NY 10; 79- 2400 .
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