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BOX 33
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04312
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICLAL USE ONLY
(35T-0
ITE LOCATION �� (� E k it i Lc A cce w �� TM# 9q.
(DATE WNER'S NAME InIC'I"T• 2e� *S Kv ICS PHONE EZ6/ —
AILING ADDRESS PV T��A c�CC.F y� k \J ion
ERSON INTERVIEWED PCHD Complaint #
ame Relationship i.e., owner, tenant, etc.
f 2 TYPE FACILITY ROPOSED INSTALLER 6fl_4,6F_R_T PHONE yr26 "�S �lS
ADDRESS aSc�_V-k c LKW J� JOSZK REGISTRATION# eG 139-
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.
Y; as owner; of epcirted ant of owner agree-to-the condition "stated- 6if' is-form::
SIGN A o TITLE %i /q_ DATE 2
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.
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 99ML
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