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BOX 16
01807
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01807
PUTNAM COUN'T'Y HEALTH DEPART
„ DIVISION.OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SENkGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME LJ p_
SITE LOCATION a a-i --
MAILING ADDRESS FaS f- -REA-MACZ
PHONE
TO
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER I.-au P- GW CC PHONE .2 7 9 -3;z 8 S
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 fran licensed professional engineer or
registered architect.
Proposal approved Proposal Disapproved
Inspector's Signature & Title
r� e
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 canponents 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
drywalls 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.
SIGNATURE TITLE DATE
X16: Vtd a (MD); YeUcw (m SI); Pink (kV it ent)