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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONNENIAL HEALTH SERVICES
OWNER'S NAME
SITE I=TION
MAILING ADDRESS
PERSON INTERVIEWED
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PHONE .� ?
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Pw Cc wlaint #
Dame & Relationship (i.e, owner, nt, etc.)
p TYPE FACILITY
u'� U PD D3C qCR PHONE
REGISTRATION # �c / F- *710e3-oAi) NY i 63 -ooh
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.
Proposal approved Proposal Disapproved.
Inspector's 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 ccmponents 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
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.
TITLE �i�(j I2 �° a 1Z� DATE o2
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