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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
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PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant,
DATE TYPE FACILITY douSe
PROPOSED INSTALLER S� qL
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ADDRESS o� � n&S o�, C.�I 1A hs d(e��t� 1" REGISTRATION# /1-o4 85.0-
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.
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I, as owner, o r rted agent of owner agree to the conditions stated on this form.
SIGNATURE TITLE DATE
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 pe ormed 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
6 X9-3 /® s
DATE
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT Sheet of %
INSPECTION
NAME ��� R. 60-1 Orig. Routine
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MAILING ADDRESS
P.O. Box Post Office Zip Code
TELEPHONE
PERSON IN CHARGE (�
OR INTERVIEWED 14V A R g f C c L6-07,, s
11 Name and Title
DATE TYPE FACILITY �P
TIME ARRIVED / iq/' I TIME LEFT Q • .Q.� -j
_ Orig. Complain
Orig. Request
Ccmpl iance
Canplaint Camp.
Final
_ Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
FINDINGS:
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INSPECTOR: TELEPHONE:
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PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
Explain
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