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01259
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIE
a PUTNAM COUNTY. HEALTH DEPARM -2 'P
:.r. _.._... - CIVIS.ION- -P EMNIVIROI M- M.M- - SF.�VICES._
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225 -0316 ��
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE
To
n(.e) AJrir Pa1D Caripl.aint #
.e, owner,tenant, etc.)
TYPE FACILITY
rV47 /a�N C r PHONE �r
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Proposal (include sketch locating all adjacent wells):
NO►m 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 architNt. i
�-Pur'
�PURI
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Proposal roved Proposal Disapproved
( xA
r
6-13
Ins is Signat j e & T n 5�,✓ I Date
Proposal 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' sleep
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to bey performed in accordance with the above proposal and conditions.
I, as owner, o reporte& agen of agree to the above conditions.
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SIGNATURE ��%�"7 �l"�/ TITLE �' %� DATE
IMES: Wute MV; Yellow- (Tam EI); Pink Ck#icent)
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