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BOX 10
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00936
SITE LOCATION g
OWNER'S NAMEM
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
/- / 6 / 6,5-
PERSON INTERVIEWED GlSll i ®u PCHD Complaint #
�"`f�ame a aeons Ip I.e., owner, tenant, etc.
DATE
PROPOSED INSTALLER
ADDRESS
TYPE FACILITY V—e,5 .
PHONE 9X =
,REGISTRATION#
Proposal (include skethch 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.
y
I, as owner, or reporte agent of owner to the conditions stated on this form. ,/ ,/
04 SIGNATURE q TITLE DATE �J OJ
Proposal approved lowin 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.
Proposal approved
s
Ile
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE