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OWNER'S NAME
SITE LOCATION
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOS SYSTEM REPAIR D
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P9 A- 41.06
Name & Relations]
PROPOSED INSTALLER J o
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(Le, owner, tez
PCHD Complaint #
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TYPE FACILITY � cry
PHONE "703. 7 VA — "a9' .07
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.
.. P�daase�. u�t�6�e�n 80►�
Proposal approved
Inspector's Signature 649ritle
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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 canponents - 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 performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to.the ai5v conditions,.
SIGNATURE TITLE. DATE
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WW: %dba (PDD); YeUcxw (fin ED; Pink (Applicant)