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01130
OWNER'S NAME J
SITE LOCATION
MAILING ADDRESS
DIVISION OF ENVIRONMENTAL HEALTH SKMCES
PUTNAM COUNTY HEALTH DEPARTMENT
PROPOSAL •' SEKkGE DISPOSAL REPAIR-
1
F� _!.I . / a. 1
PERSON INTERVIEWED Pa1D Canplaint #
•-� Name &Relationship (i.e, owner,tenant,, etc.)
DATE � °"� J ' � TYPE FACILITY
PROPOSED INSTA11ER 6a?-Z-4S PHONE Z
REGISTRATION #
Pro (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.. -.i D
K MIM - rd M I .,
Proposal approved Proposal Disapproved
Inspector's Signature & Title
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' 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 apftt.,of owner agree to the above conditions.
SIGNATURE TITLE 0111E 3_ ZT 00
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