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01243
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMEWAL HEALTH SERVICES
-_.___-....._..__=.:.-----------•--
- PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER' S NAME 0e • eeLr PHONE �'/�/ 27f .102-
SITE IACATION 7� ( '� <IAW �' - l�1�'!lb2�nzJ y,- 1246 ? To ,� &r i - g7
MAILING ADDRESS S
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, comer, tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLM Zri���
PHONE 91s� 2 -,1- 6O.1r
Fro (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.
Proposal
'�� :�/ _ • _1I: ; � it _ _.... L: - M� :. s
Proposal Disapproved
's Sianature & Title
with the following conditions:
P-AEL-3/
/ pate
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 components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concretelseptic 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 of owner agree to the above condditions,.
SIGNATURE eQ TITLE ��uek-,, DATE
DPW: WAte MD); YeUcw (Tain BI); Pink (Applicant)
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