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BOX 17
01861
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENIAL HEALTH SERVICES
PROPOSAL FUR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE
PERSON . INTERvI.EWED Pam) Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE LJ- ,o- .vz — TYPE 'FACILITY
PROPOSED INSTALLER
PHONE D %tf - X95 Z
REGISTRATION #
Pro (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 frcm licensed professional engineer or
registered architect.
4'
Inspector's Signature & Title
Proposal Disapproved
�d T
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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 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 re agent o__owner' agree to the above conditions.
SIGNATURE TITLE DATE
OPIES: Write (PLED); Yellow (Tarn HE); Pink LklAi®nt)