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BOX 18
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02071
PUTNAM COUNTY HEALTH DEPARDIP
DIVISION OF .ENVIROWMAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION
MAILING ADDRESS
PHONE- 7c�"`�4oL
TM#
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE /O i9 9S— TYPE FACILITY b�r,e„
PROPOSED INSTALLER Qre" -s 0'resl PHONE
REGISTRATION # fl?�
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 architept.
A
Proposal approved Proposal Disapproved
Inspector's Siqnature & Title
Proposal annroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
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Date
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(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, o reported agent of owner agree to the above conditions.
SIGNATURE TITLE 0111 DATE
PIES: (MD); Yellow (kin ffi); Pink (Apptiamt)