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BOX 18
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01946
PUTNAM COUNTY HEALTH DEPAR'Il�NP
DIVISION OF ENVIRONMENIAL HEALTH SERVICES
225 -0310
PROPOSAL,.. FOR SEMGE DISPOSAL.- SYSTEM :REPAIR
OWNER' S NAME N 1 C K y )- A :J O! 1 - %I! PHONE
SITE LOCATION
MAILING ADDRESS
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PERSON INTERVIEWED PCEID Complaint �
Name &Relationship (i.e, owner tenant, etc.).
DATE TYPE FACILITY
PROPOSED INSTALLER ,® S e- J/-� R l 061 PHONE Z9
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.
RC X 3; 0
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Inspector's Signature &
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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' 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
CEM: White (MD); YeU w (fin ]I<); Pink (,Applicant)
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