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BOX 18
02029
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02029
PUTNAM COUNTY HEALTH .E• • ► ►E
PROPOSAL DIVISION OF ENVIRONMENTAL HEALTH SERVICES
•• SEWAGE DISPOSAL - X►..I.
SITE LOCATION
MAILING ADDRESS.
PERSON INTERVIEWED
DATE
PHONE _ S! ?<'
cor /L /Z-60 , AU",, it6 z
TO /G?
PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PHONE A7f - 6'a65
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 fran licensed professional engineer or
registered architect.
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Proposal approved Proposal Disapproved
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.
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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' 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. L
SIGNATURE C TITLE DATE • ` /
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