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BOX 15
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SITE LOCATION'
OWNER'S NAME S
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
TM# :3 q-.1.7 ealkCs66n
PHONE 2-,7 9- 633 r
PERSON INTERVIEWED r r- ears PCHD Complaint #
Name & Kelationship i.e., owner, tenant, etc.) A
DATE) 11 q I (� TYPE FACILITY res t d e-k,c e
PROPOSED INSTALLER ,� rt s[ %►'►S -,PHONE O cf
:11-11 ,
REGISTRATION# R3
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.
I; as- tee:=; or-le- rted agent of ovviter,agree to°uie conditions stated utr•tlAs-for-ui. - --
SIGNATURE TITLE GS _ DATE t1 l 4 16 s'
Proposal approveimit a 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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be p�ormed in accordance with the above proposal and conditions.
Proposal approved,
/ep
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
TYNDALL EXCAVATING CONTRATORS
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Farm To Market rd