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BOX 18
01949
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01949
OWNER'S NAME
SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMENT'
IVISION OF ENVIRONMENTAL HEALTH SERVICES
ROPOSAL FOR SEW= DISPOSAL, SYSTEM REPAIR �
a, 12n A T! PHONE
17 -I61 44r- /Or/ I - l Sid 18,21 • To A.LW9A
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER y PHONE c 6 3 6;Z Q
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.
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Proposal apprqyv_esl� Proposal Disapproved
s Signature & Title netAr
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
drywalls 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 t; TITLE DATE
L. & V&te (FOLD); Yellow (fin HE); Pick Valianit)