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BOX 6
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00267
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICL&L SE ONLY
SITE LOCATION O 40r I R R T--311 I TM#
OWNER'S NAME 7aHly h l0 PHONE 97,Y �6
MAILING ADDRESS AoY SI ZW d `3
PERSON INTERVIEWED MMR oHN :TAYL PCHD Complaint #
Name - kelations p i.e., owner, tenant, etc.
DATE 2 —? 0 TYPE FACILITY .
PROPOSED INSTALLER PHONE C� N -4pX 9
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ADDRESS J114 STARR RIDGE RD . REGISTRATION#
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 owner agree to the conditions stated on this form.
SIGNATURE �` TITLE DATE /' —�
Proposal ap=ved 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 performed in accordance with the above proposal and conditions.
Proposalapproved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
/ 3! �`�1�-� 100,
DATE
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