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BOX 11
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01074
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SITE LOCATION _
MAILING ADDRESS
PHONE o;(
PERSON INTERVIEWED `� i C,h Pa1D Complaint $
Name & Relationship (i.e,.owner, tenant, etc.) -- -
DAM TYPE FACILITY
PROPOSED INSTALLER PHONE
Proposal (include sketch locating all adjacent wells):
Nam: Repair must be 'in same. location and of same type as` original sewage disposal system.
Different location may 'require subnittal'of. proposal fram licensed professional engineer or
'registered architect.
M
Proposaloved Proposal Disapproved
s Sicmature &
to=.11 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g. house corners).
three precast 6' diam. x 6' deep
3. 'System repair to be performed in accordance with the above proposal and conditions.
1, as own or reported agent of er ree to the above conditions.
SIGNATURE • TITLE C LA)A)e Z GATE O I' O' /
vy
MM: Vbite (PC D); YeUc w (Tam ffi); Pink (A ali®nt)
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-� PUTNAM COUNTY HEALTH DEPARUMU
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225-0110 ' �I
PROPOSAL RE SE&VMGE DISPOSAL SYSTEM REPAnt
oi�NER's.NAME - - (��'�1,-N� ZiPFe �. PHCNE �-V
-390
SITE : LOCATION TK#.
MAILING ADDRESSd
PERSON INTERVIEWED � � '• Pam) Canplaint #
Name, &`Relationship (iie,.owner, tenant, etc.)
DATE TYPE FACILITY
PROPOSED DETALI,ER PHONE
(include sketch locating all adjacent wells):
NOTE: Repair must .bein, 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.
MP._M
Proposal approved
Proposal Disapproved
Inspector's Signature & Title Date
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 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.
3.- System repair to be perfonred in accordance with the above proposal and conditions.
I, as ownT or eported agent o own gree to the above conditions_.
SIGNATURE 9` TIME ( UAeZ DATE
XFW: %Ate MD); YeUc w (Tam ffi); Pink (Alticant)
IS7
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a
OWNEE
SITE
MAILING ADDRESS
5 P A-n `P
E
PERSON INTERVIEWED 111aa CIt M_ � /.vt. E--J.I ) PCHD Camplaint # k= - 555 -19
Name & Relation hip U.e, own , t, etc.)
DATE TYPE FACILITY
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 fran licensed professional engineer or,
registered architect, /
'AN LIJA P f� v d 11) ir'?c' �'v l Gt 1 f1i / /Uc,' /)t.re C-JA.: k'P
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Proposal approved �(_ Proposal Disapproved
W nature & Title
)roved with the following - conditions:
/ Y Date
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 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 performed in accordance with the above proposal and conditions.
I, as owner, or reported agent 6f wner agree to the above conditions.
SIGNATURE TITLE iz°S'�(.�,C�' DATE
/ I Y
PM: (White MV; Yellcw (fin HI); Pink (Applicant)