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BOX 22
02571
PUTNAM COUNTY HEALTH DEPARTMEIT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME A N G K EUiJ PHONE
SITE LOCATION 7M#
MAILING ADDRESS 14t V S G (+ W +N Va 1� r5 �] �u N +� r1 U Lu Ny 105-1R
PERSON INTERWEWED PCHD Complaint # -
Name & Relationship (i.e, owner,tenant, etc.)
DATE L2_1i L2_1 141, C, _, TYPE FACILITY pgj y S, f +0yJ E_
PROPOSED INSTALLER + -gf_aX Guft,� PHONE Sa �S -o(oCp
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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SEE (4wr4ct+co Su(Z.1J G-y �oZ wcn-n o f� UP
r- l t' L-DS d- W f,LLS
Pro a raved Proposal Disapproved
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1�fspecforls Signature -& Title bate
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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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, or17 reported agent of owner agree to the above conditions. `�
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