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BOX 14
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PU NAM COUNTY HEALTH DEPARDWT
DIVISION OF.ENVIRONMEJPAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME A / / e h
SITE LOCATION /39 Bur /
MAILING ADDRESS ,
PERSON INTERVIEWED
DATE
111- XI ID
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PHONE 67141)v:�Ar' 7,08 yc
D W r7 E' r' 4v4 4r, i6T s ®q_) PCHD Complaint #
Relationship, i.e, er,tenan etc.)
TYPE FACILITY
PHONE
REGISTRATION #
Proposal (include sketch ting 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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Proposal approved
Inspector's Signature & Title
to
`roposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2...SuL - mission 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' diam. x 6' 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 reported a t of owner agree to the above conditions. G
SIGNATURE TI D1ATE� /
IP1�:5: White (PC D); Yellnw (fin ED; Pink (Anikant)
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