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BOX 33
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PERMITTEE
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SITE LOCATION ? ND
Repair Permit #R -_�% --
PUTNAM COUNTY HEALTH. DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 - 3838/225- 3833/225 -3641
SEWAGE DISPOSAL SYSTEM REPAIR PERMIT
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MAILING ADDRESS R Q '-� Stmt BOX 8z U) (k ii`i= u) %�✓ '-'~�
PERSON INTERVIEWED P , to r tS C,,3pJ CsY'� PCHD Complaint # ----
N3M & 1121a-irnEt-ip (i.e., (Xier, temnt, etc.
DATE QiD0CV)
- UNNG a0u" Lq TYPE FACILITY OT Z�`
PROPOSED INSTALLER' L A 57 (skm J c en e, PHONE
Proposal (include sketch locating all adjacent wells): weI-L
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PERT e 1-VC
Proposal not approved for the following reason (s):
j Permit issued with the following conditions:
1. Notification of PCHD prior to backfill to permit inspection.
2. Procurement of any necessary Town permit.
3. Submission of a 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 tank, three 6" diam. x 6' deep drywells
surrounded by one foot + gravel).
e. Installer's name and number.
4. Compliance with the conditions of this approval is the responsibility of the property owner.
5. Other
NSPECTOR SIGNATURE
ERMITTEE SIGNATURE
DATE
P-41 DATE
rHER SIGNATURE DATE
relationship to permittee
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