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BOX 12
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01242
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SITE LOCATION
OWNER'S NAME_
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSALSYSTEM REPAi L
OFFICIAL USE ONLY
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PERSON INTERVIEWED Do P gddi PL IL eed n L45 jj e-✓ PCHD Complaint #
, I t Narne a ations ip i.e., owner, tenant, etc.
DATE (o/�- % /t�.S f
PROPOSED INSTALLER'�/L� // jW TIG
TYPE FACILITY
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ADDRESS dO SVY #1 W GISTRATION# �3
Proposal (include sket h 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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1, as owner, or reported agent of own r agree to thdWnditions stated on this form. -
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SIGNATURE TITLE �/'^G DATE e
Proposal e with t 9 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 StreetName, 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
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal pro d
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
J
T -2 -05
House
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0 1,050 gal plane septic tank
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