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PUTNAM COUNTY HEALTH DEPARTMW
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME
SITE LOCATION
st- 9-i7-F4
PHONE _00s"'' Y3�
TO
MAILING ADDRESS &me,
PERSON INTERVIEWID �o�n s(/ ny��'s PCHD Camplaint #
Name & ationship (i.e, owner tenant, etc / / -q� TYPE FACILITY�►'It.
PROPOSED INSTALLER T, /t 4;to PHONE
REGISTRATION # PC- D
Pro (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. I_ _ I � ;1_ ' II
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Proposal approved ,J� Proposal Disapproved
1 .
2.
3.
)r's Signature & Title
)roved with the following conditions:
Procurement of any Town permit, if applicable.
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 6'
drywells surrounded by one foot + gravel).
e. Installer's name and number.
System repair to be performed in accordance with the above proposal and conditions.
was owner, reported agent of owner agree to the above conditions.
SIGNATURE ,b TITLE DATE
PIN'S: White (PCHD): YeUcw (Tom BI); Pink (Anl amt)
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Name &
Wt., <r.)
(1.e, owner,
•ice,
Pty Complaint 0
TYPE FACILITY /nC
PHA
REGISTRATION # V ply J'31
Proposal (include sketch locating all adjacent wells):
NTE: 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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Proposal approved
s
&
Disapproved
qtr,
,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 lame, 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' diam. x 6' deep
drywel.ls 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 agent of owner agree to the above conditions.
SIGMURE TITLE DATE
Ili: ftte MV; YeUc w Marm HL) ® Pink (Apliamt)