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01072
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01072
PUTNAM COUNTY HEALTH DEPARTMENT j
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225=0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
-1�1 8 3
OWMIS NAME :. } �I �S Cook PH= 9279 g
SITE LOCATION
MAILING ADDRESS �� D �L � 09 Q O � � P/4 �Ei2S'o A) ik) � /*t s lc 3
PERSON INTERVIEWW PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
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 'ttall of pro from licensed professional engineer
registered rcfiitect� A A/ 1� p % -V-M C n YA e LCD 1h 4�T)
2.
3.
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Proposal Disapproved
2-'C
D' to
osal approved with the following conditions:
Procurement of any Town permit, if applicable.
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions. .
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