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BOX 13
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01369
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL; FOR._SEi AM"DISPOSAL'7MTW- -PM,AIR-
OWNER'S NAME JESSIE JACKSON PHONE 279 -8993
SITE LOCATION 3 ALDEN ROAD 714#
MAILING ADDRESS PATTERSON, NE
PEON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER
PHONE
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 submitji'�l bf proposal from' licensed professional engineer or
registered architect, ��g(
Proposal
s Sianature & Title
S "p, B
Proposal Disapproved
/ Z 4/1/
Date
roposal 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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast.6' diem. x 61 deep
drywells 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 ent of owner agr to the above nditions.
or
SIGNATURE TITLE DATE
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