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BOX 13
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01366
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
pgopoSAL FOR SEWAGE DISPOSAL SYSTEM "PAIR
OFFICIAL USE ONLY
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SITE LOCATION
OWNER'S NAM[E'5ahei i I? ,c I M PHO 79-3 i G cE
MAILING ADDRESS. J cl � /o/ ,e W/y/ e,- S.�,e -7
:PERSON INTERVIEWED r L A A JQI� CC- PCHD Compl aint #
Name & Relationship ki.e., owner, tenant, Fit.)
DATE TYPE FACILITY
0 -J 'PHONE L7 2- V
PROPOSED INSTALLEiD �IeAxr- Iz-
ADDRESS 14.%N&4 ' V&4 Dr.,, 4c- 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.
as owiier, OF reportted agent of owner agree -to the conditions stated on this fornn.-
SIGNATURE :`
TITLE 0 L4, IV
U
DATE 3
A
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 I&TE/
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC-RP 99ML
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