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BOX 12
01196
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01196
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PUTNAM COUNTY HEALTH DEPARTMENT
ZVWOQI 'SAL_ HEALTH SERVICES
225"05lb
PROPOSAL FOR SEKAGE DISPOSAL SYSTEM.REPAIR
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OWNER'S NAME ofe-4 g.'4- r P 1 *1 ' 1 -5 ' e,.
9 — V P. PHONE ,2 2
SITE I=TION TO
MAILING ADDRESS
PERSON INTERVIEWED PCHD. Caq3laint #
Nam & Relationship (i.e, owner,,tenant-, etc.)"
DATE b-10- q TYPE FACILITY
PROPOSED INSTALLER icy, 47 v --,k- `,S n "a Him
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 liciensed professional engineer or
registered architect.
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Proposal approved Proposal _pisapproved _
Inspector's Signature &
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Proposal approved with'the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submisqion 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 oorners).
d. System description (e.g.,, 1250 gal. concrete ' septic tank,, three precast 61 diem. x 61 deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfonned in accordance with the above proposal and conditions.
as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TIME DATE
7; WAbe alm; YeUcw (Tam Ell); Pink (An2liaint)
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