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BOX 35
04697
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04697
0itm I S NAME
SITE LOCATION
MAILING ADDRESS - )
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225-0310
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QPOSAL - F
PERSON INTERVIEWED L.-Iti PCHD CaTplaint
Nam & Relationship (i.e, owner,teriant, etc.)
4,� I TYPE FACILITY
DATE Dfil-7,N-11z
PROPOSED INSTALLER w aajm--c W PHONE P
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 mad require submittal of-proposal fram licensed.professional engineer or,
registered architect.-
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Proposal approved
Proposal Disapproved
Inspector's Signature &
with the following conditions:
F/2-7zl zal
t Date
1. Procurement of any Town permit, it-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 camponents tied-to two fixed points (e.g.Ihousd corners).
d. System description (e.g., 1250 gal. concrete septic tank,, three precast 61.diam. x 61 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,, or reported agent of owner agree to the above conditions.
SIGNATURE r TITLE DATE
I WBS: Vbibe (MD); Yd1cw (kn EI); Pink OnikEint)