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00272
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00272
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
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SITE LOCATION f U Q i Sah d" %,o t.L r I. /tea I I v-N rMiF
OWNER'S NAME .r' 14 ,L z PHONE Y7 $' - 9s'6 y
MAILING ADDRESS j-7S- C4,ss a n d r-u Lv t--w+ t f *r t cs n,, Al
PERSON INTERVIEWED Rc b er— L4 z z 0 PCHD Complaint #
—Name a ations ip i.e., owner, tenant, etc.
DATE TYPE FACILITY k cS iden.C,,�
PROPOSED INSTALLER �` ` t"�/nS SHONE k Y s�' Z %
ADDRESS U �I r2us �r_r VREGISTRATION# 9 3
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, or reported agent of owner agree to the conditions stated on this form.
SIGNATURE TITLE DATE .3//,/�
Proposal approved 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.
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Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Eihlc (applicant)
PC -RP 99ML
ri DATE