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IN 6
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01236
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01236
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FUR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME Joe: PHONE
SITE LOCATION I)r /.W?� TO
MAILING ADDRESS Srr•e
PERSON INTERVIEWED Cpl i,,a1. PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE is :w-?6 TYPE FACILITY
PROPOSED INSTALLER PHONE
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 from licensed professional engineer or
registered architect.
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Proposal approved Proposal Disapproved
with '1
conditions:
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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' 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 agent Hof owner agree to the above conditions.
SIGNATURE 0 -- :/6 TITLE
OP1E5:
Write MD); YeUjcw (fin ED; Pink (AppLiamt)
DATE 10 ,4 C.