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PUI'NAM ODUNTY HEALTH DEPARmw
DIVISION OF ENVIRONWWM HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
U
OWNER'S NAME e� ij V 1 J PHONE
SITE LOCATION ) 'Zv% TO
MAILING ADDRESS (r}j��G�Sgill
PERSON INTERVIEWED Pam) Complaint #
j� 9. Name & Relationship (i.e, owner,tenant, etc.)
DATE / / i TYPE FACILITY
PROPOSED INSTALLER
PHONE o G� o
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 a chitect.
Proposal approved Proposal Disapproved
'S Signature &
�y
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
drywalls 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 re rted agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
3PM: WAte (POFn); YeUr w (Ttkin ffi); Pink (A pliant)