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BOX 10
01012
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01012
PUI'NAM COUNTY HEALTH DEPARTMENT
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DIVISION OF MMMMIML HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL .... SYSTEM. REPAIR
OWNER'S NAME
SITE LOCATION
DATE
TM#
PCHD Complaint -#
Name & Relationship (i.e, owner,tenant, etc.)
7- TYPE FACILITY
PROPOSED INSTALLER PHONE
REGISTRATION #
Prcposal:(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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Inspector's Signature &Title D�a
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, Tarn and Tax Map number,
c. Location of installed components 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 perfonmed in accordance with the above proposal and conditions.
I, as owner, or r rted agent of owner agree to the above conditions.
SIGNATURE TITLE
PM: Whibe (PCID); YeUcw (Tam HE); Pink (k1i i®nt)