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BOX 17
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PUTNAM COUNTY HEALTH DEPARWNT
DIVISION OF ENVIRONMMAL HEALTH SERVICES ` 19
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME Z�-c 0L ,)0se- Myrrr.. V le "a hI PHCNE
SITE LOCATION Bm-a Ar 7M$
MAILING ADDRESS
DATE 1. i'=
REGISTRATION #
. per.
PCHD Complaint #
ant, etc.)
TYPE FACILITY &A e
PHONE f /5- fJ`3r---:&7J
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 from licensed professional engineer or
registered architect.. ,
rC
Proposal approved / Proposal Disapproved
's Siqnature & Title
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 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 perfonned in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATUREt
CPINIS: whi, (MD); Ye]1aw MU; Pink (AFplusnt)
TITLE AnOv. DATE Ce -11 J'do