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01229
PUI'NAM COUNTY HEALTH DEPARMMENT
DIVISION OF ENVIRMMIMAL HEALTH SERVICES
..... ' 'PROPOSAL FOIL SEJOGE DI SPOSAL SYSTEM REPAIR /
OWNER'S NAME 1ft7 kel PHONE 079 r7,0 7
SITE LOCATION q'' l 7 Zoee r srJ mil# Xf - z • 4%�
FAILING ADDRESS
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner tenant, etc.)
DATE TYPE FACILITY C-3
PROPOSED INSTAUM PHONE 6o69
REGISTRATION # QS/y
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.
L'x tL� 071 C� i9Z cox l .S /Jim
.L.
2.
3.
�woj W�-1
's Signature &
V%sal approved with the following conditions:
Procurement of any'Town permit, if applicable.'
Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Nation of installed eanponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem.
drywalls surrounded by one foot + gravel).
e. Installer's rain- and number.
System repair to be performed in accordance with the above proposal and conditions.
x 6' deep
I, as owner,
or reported agent of owner agree
to the above conditions.
SIGNATURE .
TITLE
DATE l
L'Pg14: white MD); YeUcw (un HI); Pink (A;#imit)
PC -RP 97
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-71t