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00031
-PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
SITE LOCATION /(-Y - TM# '�f-/6 - -/ -33
OWNER'S NAME EgDi4 k0w PHONE
MAILING ADDRESS" ,n� �,� .> "�A, � , 41-Y - lza3
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
DATE
PROPOSEDINSTALLER
TYPE FACILITY oe c
PHONE 479' 6o0j
ADDRESS _ ' ,, �, �, ;� �,� REGISTRATION# ) C. tff-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
Tay require submittal of proposal from licensed professional engineer or registered architect.
75zr.A tea. . _., 17-1 .01W
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I; as owner, or re brted agent of owner agree to the conditions stated on this form.
SIGNATURE AM TITLE DATE J •�j
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Proposal approved with the followine 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.
AFOP
osal approved
Inspector's Signature & Title DA
COPIES: White (PCID); Yellow (Town BI); Pink (applicant)
PC -RP 99IVIL
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