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01274
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01274
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION
OWNER'S NAME .�
MAILING ADDRESS.
OFFICIAL USE ONLY
3 3S-o,3
TM #OtJ
PHONE ,S�
PERSON INTERVIEWED &4 PCHD Complaint #
ame & RelFt—ionship i.e., owner, tenant, etc.
DATE 10--X ',
TYPE FACILITY
PROPOSED INSTALLER .. .�L. bg& PHONE
ADDRESS /� � REGISTRATION#
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.
await
_ _ ......J,.ns.Qwner., or..reported a ent of owner agree to. the conditi.nnc.stated on-this.form.
SIGNATURE TITLE 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 components tied to two fixed points (e.g.,house comers).
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 approved
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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