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BOX 13
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01360
PUTNAM COUNTY HEALTH DEPAR'IlMNT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 =0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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OWNER'S NAME DAN O' CONNELL PHONE 279 -4187
SITE LOCATION 4 ,SUMMIT RD TM#
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
RESIDENCE
PROPOSED INSTALLER BOTTGE SEPTIC, INC PHONE 279 -6069
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.
Proposal approv Proposal Disapproved
Inspector's Signature & e
Proposal avnroved with the followinu 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.
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c. Location of installed ccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
dryw ells 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 ent of owner agree to the above conditions.
SIGNATURE 4 TITLE DATE
MES: Rdte (MD); YeUc w (fin BI); Pink (Applicant)
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