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01220
PUTNAM COUNTY HEALTH DEPARTMENT
--PI�9SION. OF- ENVIRONMENTAL HEALTH SERVICES
PWPOSn FM SEMM DI SP OSAL SYSTE K REPAIR
OWNER'S NAME T in &I-0-se PHONE
SITE LOCATION Or AP6,? 71
MAILING ADDRESS
PERSON INTERVIEWED Dr,. PCHD Complaint
Name & Relationship (i.e, owner tenant, etc.)
DATE 6- i-a7 TYPE FACILITY 4^4
PROPOSED INSTALLER mimes keltcrb. 4K. !m viz /-TO PHONE 9/y d°.sr" 3S'73
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 architect.
To A, shl/ e PJ c.. etas a4
(M
Proposal approved.
Inspector's
ture &
Proposal Disapproved
PrA
toposal 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 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.
3. 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.
SIGNATURE TITLE �,�c/�v- DATE �-�-6p
TITFS: White (EC D); Yellow 03an BI); Pink Vql amt)
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