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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONIvfENTAL HEALTH SERVICES
OMCLU USE ONLY
SITE LOCATION 11_ l3lr� �,/_ r TM#
OWNER'S NAMEi� [, G'. s PHONE �S' V-2
MAILING ADDRESf► it lei. c.� c�.o�y _ �v /- _r
PERSON INTERVIEWED PCHD Complaint #
Nam I RelaWo-wMip Le., owner, etc.) --
DATE ? YPE FACILITY
PROPOSED INSTALLER. Al
ADDRESS
RATION#
Proposal (include sketch locating all adjacent weR i):
NOTE: Repair must be in same location and of same We as original sevmge 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 nn z - DAIE
Prppoal ap=yed Affi th!; folyLing sand 'o=
I . 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., 125o gal. Conc reW septic tank, three precast 6' diam. X G deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
P approved_
Inspector's Signature .& Title DATE
COPIES: WI& (POID); 'Yellow (Town Do$ Pink (applicant)
PC-RP 99ML
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-,06y19/2003 09:26 1-973-764-6404 ALL COUNTY RESOURCE PAGE 02
Be Maple Grange Rd, Vernon, NJ 07462
140*428-6158
Job Name Customer #
Address - /I B il'erA wcw
City gafflgg.. State
Block Lot
Home Phone # rr, Date 19 !e.?
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