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BOX 15
01640
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01640
OWNER'S NAME
SITE LOCATION
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PUTNAM COUNTY HEALTH DEPARTM01T
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR - �--
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PERSON INTERVIEWED PCHD Caaplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER ���i�- �"rt e I"c 7Y7) PHONE 2 7%'
REGISTRATIOV #
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. /S %�Nls 5ys7�/n Ans 98 apf 0100,,'z dvtiz Asir /�5
Proposal approved
Inspector's Signature &
Proposal Disapproved
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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 Tex Map number.
c. Location of installed components tied to two fixed points (e.g.,hcuse 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 re ent of owner agree to the above conditions.
SIGNATURE TITLE GATE lot
PBS: White (PQ•D); Yelljcw (Ti K); Pink 011li,cant)