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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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SITE LOCATION TM# -3 6 `f% -/-/A'
OWNER'S NAME Z2,1b t-17iff �, F/� � t' %rib c -�" PHONE t�' S = 2 �e-I'S T
MAILING ADDRESS 2 7 Ly 2 6-'d -1A4 ) 4 %3R Jy-,Ii �`� N Y /0�yy
PERSON INTERVIEWED ad/-O-jr oN�r,� c�c «i G2 PCHD Complaint #
Name & Relationstilp i.e., owner, tenant, etc.
DATE / / - / L z-o 0
PROPOSED INSTALLER
ADDRESS
TYPE FACILITY
I' . • ►!
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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I, as owner, or reported agent of owner agree to the conditions stated on this form. 4
SIGNATURE ,f� TITLE '1`'4t -1i1W A ff'-rcbDATE
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.
Proposal approved_
Inspector's Signature & Title A
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
4_ -
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR`
OFFICIAL USE ONLY
PERSON INTERVIEWED
TM# �1 1-7 40 'F
otec.-Pfim )Dg
V (5 �/lJ PHONE �j _
z4QiV PCHD Complaint #
DATE TYPE FACILITY,
PROPOSED INSTALLER �J 6 64,4- e /,Q , PHONE 20
ADDRESS �13 7/id IV W1 REGISTRATION#
7,16 ZY0 7
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.
conditions stated on.this form.. _.
ITLE DATE
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.
Proposal approved_
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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