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BOX 18
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01947
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'?R0P0SAL FOR SEWAGE7DISVOS�--SY T
SITE LOCATION i k.
OWNER'S NAMES
MAILING ADDRESS
,PdAI�jn nA Lf) k 2 TM#
OFFICIAL USE ONLY
PERSON INTERVIEWED PCHD Complaint #
I _ , Name & Relationship i.e., owner, tenant,. etc.
DATE
PROPOSED
ADDRESS
TALLER
1 2-� °T C,
TYPE FACILITY
PHONE
ORATION#
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.
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I, as owner, or reporte agent of weer agree to the conditions stated on this form.
XSIGNATURE C. TITLE (9 LN4 6r DATE � i
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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 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.
Proposalapproved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
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