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BOX 17
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01895
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01895
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR-SEWAGE PO u BEPAI �
SITE LOCATION �' i�I: ,/? TM# ei
OWNER'S NAME _ Gus,e_n PHONE
MAILING ADDRESS
9�_ >3, e w'Al
OFFICIAL USE ONLY
' zn1'
PERSON INTERVIEWED a - PCHD Complaint #
ame Re la Ip i.e., owner, tenant, etc.
DATE 3 2-- TYPE FACILITY /nr e-
PROPOSED INSTALLER J �,�ej Cq_. PHONE
ADDRESS 7 7 !' .sot F%,, i�lJV i? V /_), 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.
-Cf,
Z17
ink cvz be ,[
I;-as -owner; or reported agent o owner agree to the conditions stated on this form.
SIGNATURE �Yi' £'� TITLE
P101205 ` v e following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
DATE Z: / /_/
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 performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title /ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
1�
OT
OWNER'S NAME PHONE .7 f �f6
SITE IMATION 70 -
ADDRESSn�
PERSON n0MVIEWED PAID Congalaint #
2 / Name & Relationship (i.er owner,tenant, etc.)
DATE ' C/ TYPE FACILITY
.; &-PROPOSED IlSSTMJM PHCNE
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.
U
Proposal approved Proposal Disapproved
.Inspector's Siqnature & Title — —� Date
with the followinq condi
1. rtCX.'frliMUMAl. UL CULY ivwai rGiuua., ii
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
(e.g. house corners).
three precast 6' diam. x 6' sleep
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.
SIGNUE)RE l_ l TITLE DATE 01
White MED); Yellow Mvn ffi)B Pick LkVUaant)
PC -RP 97