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BOX 3
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION f i
OWNER'S NAME
MAILING ADDRESS 4
OFFICIAL USE ONLY
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PHONE gf7A- 3/ &7
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc.
DATE TYPE FACILITY -
PROPOSED INSTALLER PHONE i�" - — �° g
ADDRESS � � (Ai • 6;W-;V REGISTRATION# G- W- A
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.
I, as owner, or reported agent of pwner agree to the conditions stated on this form.
SIGNATURE TITLE DATE
Proposal annroved 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.
3. 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)
DATE
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PQ5;FMk,m, CA)r.-014 C77EWe
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