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02332
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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 A K 93 V -7 5' � D TM#
OWNER'S NAME ZNs Ci4,rX1 PHONE 6,2r- c;?,F I
MAILING ADDRESS C 0• s-
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
DATE /6 /.-O k TYPE FACILITY 9 S^
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PROPOSED INSTALLER 4A..-u1~ Ci4$6 E/t I— PHONE SLR' `r,7 5- S�
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ADDRESS ► - K W I/ A L �� 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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SIGNATURE TITLE E'ILL T DATE Q a Lo
Proposal approved with the following conditions:
1 Procurement of any Town permit, if applicable.
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 corners).
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 rformed in accordance with the above proposal and conditions.
Proposal approved
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(Sector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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