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BOX 10
01019
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01019
PT.JTNAM COUNTY HEALTH DEPARTMENT
V
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
U l 3's-C-) rQ
SITE LOCATION j
TM# -7 - ^ 70
OWNER'S
PHONE IT-16`10
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE
TYPE FACILITY
PROPOSED INSTALLERS awa rrnse o.0[- c; S e` il,'c P PHONED d -316 3
ADDRESS �4 q ,,.c � 14446 A %,� S �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'sta�ted oh -this. form......... ____..._....r...,.._, .,__�.._........ ___ ._.. _.
SIGNATUREL J P _ - TITLE -L Lam(' v DATE 1
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, 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.
Inspector's Signature & Title /DAT
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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