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BOX 15
01613
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01613
OWNER'S NAME
SITE LOCATION
PUI'NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR S3-AGE DISPOSAL SYSTEM REPAIR
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PERSON INTERVIEWED PCHD C Vlaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
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.
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Proposal approved Y� Proposal Disapproved
Inspector's Signature & Title
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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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 repo agent of owner agree to the above conditions.
SIGNATURE TITLE DATE-17/,z-,/9,,-
PM: ?&be (PCED); Yellow (Tvn HE); Pink 0011amt)