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BOX 16
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01811
MUM'S NAIL
SITE LOCATION
MATLIW ADDRESS
14414111" IN i
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PRQPOSAL FOR SE{W DISPOSAL SYSTEM REPAIR
PHONE 2`1 j� - c
PERSON IlVTEEtVIEWED Pam) Ca:galaint #
Name & Relationship (i.e, owner Aenant, etc.)
DATE ~Z % �{. TYPE FACILITY
PROPOSED naTAUM —�''�' PH= 11 S- -i1�-6 �
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NUM: 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 architt. ( in _ t _ i
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Iroposal 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.'Iccation 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 oonditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNAZ W TIME DATE
PIES: Finite MD); YeUcw (ywn EC); Pink LzWlirsnt)
3C -RP 97
BI -STATE INC.
P. O. BOX 692
BREWSTER, N.Y. 10508
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PUi'NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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CkHMIS NAME �_�,,11 ��-. r� (� PHONE 2 "�$ X34
SITE LOCATION {Z - 22_ TO
PERSON IlNTIItVIEM 6) w k-at ,- PM Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE / 2 -2 ( -" l �1 TYPE FACILITY ►2
PROPOSED INSTALLER "'S ' PRONE r-
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. , 'IT co :r2c1
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s Signature & Title
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roposal 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 installer) 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 reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
Wr ; : ftte (FAD); Yellc w (= ED; Pink QgUawit)
PC -RP 97