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1 .1:
PUI'NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENrAL HEALTH SERVICES _
PROPOSAL POR SEWAGE DISPOSAL SYSTEM REPAIR cy
OHM, S NAME T�; G,7 B 451,41 ltlla -lc. y L �' / S -2 g S� PscNE 2 2 -s SITE I=TION lKl i' TO
FAILING ADDRESS
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PERSON INTERVIIIaED Pam Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE ,fv? -;;z TYPE FACILITY
PROPOSED INS&LlEi 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 reguire submittal of proposal fram licensed professional engineer or
registered architect.,
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Proposal approved_ y� Proposal Disapproved
Inspector's Signature & Title 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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x 6' deep
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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24000 • 00" R = 1000.00'p
L = 81.74' S 7'iB'00" W p = 04 49 00
• 208.00' L = 84.07' & °, S 77700" W
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