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BOX 13
01339
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01339
SITE LOCATION
OWNER'S NAME_
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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PERSON INTERVIEWED Tn ��ron owns/ PCHD Complaint #
NaInt & Kelationsnip I.e., owner, tenant, etc.
DATE TYPE FACILITY Ame
PROPOSED INSTALLER PHONE tNr - ,fS s" = 3s 73
ADDRESS Za 6p l >%' REGISTRATION# PZ -ey/
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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I, as- owner; -or,re orted agent 9fowner agree to the conditions stated on this form:
SIGNATURE TITLE -'n7�l )'5 // 6' DATE
Proposal ov 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