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BOX 32
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04253
PUTNAM COUNTY HEALTH DEPARTMENT
x: DIVISION_OF ENVIRONMENTAL HEALTH SERVICES
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OFFICIAL USE ONLY
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SITE LOCATION :� l 91E Ce ILL SITS TM# g'3 'L S-2 �[ —((
OWNER'S NAME &04-hlC 4:-1 N kC PHONE & r :5—ZZ �y
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Retationshit) i.e., owner. tenant. etc.
DATE l ( S 1 P
PROPOSED INSTALLER
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ADDRESS n. ,
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TYPE FACILITY RC-- S
PHONE
REGISTRATION# P C, G
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 Lkser(.(-
I, as owner, or r ported agent of owner agree to the conditions stated on this form.
SIGNATURE TITLEos� -%
DATE ti U
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 DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NIL