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SITE LOCATION
OWNER'S NAME
MAILING ADDRF
PUTNAM COUNTY HEALTH DEPARTMENT V/
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR sSv Oi i,r
OFFICIAL USE ONLY
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PERSON INTERVIEWED PCHD Complaint #
/ / Naine & Relationship (i.e., owner, tenant, etc.
DATE Z
PROPOSED INSTALLER 0491 ✓O-d —
ADDRESS
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TYPE FACILITY
PHONE N;� ;77f fY f' 57
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.
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n TI agent of o _c to the conditions stated-on this form:
SIGNA _ TITLE 64QJ_AX—,fe— DATE .�
Proposal aporoved 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.
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
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