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BOX 32
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OFFICIAL USE ONLY
SITE LOCATION 3 3 f C ft TM# 3 j— a S-0 4 S/
OWNER'S NAME rR a 3 e0-T- �c Mc e 10"C PHONE 57&
MAILING ADDRESS L-R k-V- pe ekSkl tl
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
ATE TYPE FACILITY S
PROPOSED INSTAL ER � 6 As -c'eYe ( PHONE
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ADDRESS naZr_,cs., m itAcLFv t4v, io,S 75 REGISTRATION# PC- %3 %
Proms (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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SIGNATURE .— TITLE �A— 6 �t /cL 'Pr DATE Z
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 y
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Inspector's,,Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PQ'RP 99ML
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DATE