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04197
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PUTNAM COUNTY HEALTH DEPARTMENT ' C -
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OWNER'S NAME 2� 414 4-N M1l qi4 51, 14 V c 'T 2 PHONE 472J/ A 3 /
SITE LOCATION -7 w;4 c. t( y- 1W W
MAILING ADDRESS �GC1cs 1rc V( AW q, i & -S' 7 %
PERSON INTERVIEWED PCHD Ca%aaint #
DATE iV / l
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Name & Relationship (i.e, owner, tenant, etc.)
49y 1 TYPE FACILITY
PHONE �,^ 2.{c S77 E
REGISTRATION #
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal systsm.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Proposal ap6raved - Proposal Disapproved
AP4 ?g
Ins is Signature & Title Date
Proposal approved with the followin4 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
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, r reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
PIES: Mite (PCfD): Yellaw (Ibm HI); Pink Qg2iamt)
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