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PUTNAM COUNTY HEALTH DEPARTMENT
iiTH "SERVICES". 'l,
PROPOSAL FOR SE9E DISPOSAL SYSTEM REPAIR .
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Off' S NAME 4z O-/7 /7 o �d e,-� L -a \S F' -7 PHONE 2 2 - -
SITE LOCATION W i
MAILING ADDRESS
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE -q TYPE FACILITY
PRoposm Irs Tz -l�- PHONE
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 fram licensed professional engineer or
re5 ij�tered architect. ,l
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Inspector's Signature &
Proposal Disapproved
Date
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, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
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OprOved as noted for conformance with
Pp�-ioable Hulas and Regulations of the
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