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02082
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION 0112
OWNER'S NAME—Zj
MAILING ADDRESS 0
OFFICIAL USE ONLY
R a ,31 -0 /
TM #.`r9 / Z�
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PERSON INTERVIEWED PCHD Complaint #
Name Relationship (i.e., owner, tenant, etc.
DATE TYPE FACILITY /�.��1
PROPOSED INSTALLER � jl7r� c,ry �c�� PHONE 9K,"Z757� 6665
ADDRESS 4- Soda, exi REGISTRATION# 1A2y
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.
I;_as.owner; ox,reported_agent of owner agree_to. the "conditions stated_on this_form.
SIGNATURE TITLE
/ DATE Q0-1W-Z461
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
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
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