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02634
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENrAL HEALTH SERVICES 'o -77
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
MM'S NAME PHONE
SITE LOCATION Z L� CC<--., A-4f M) TK# -� 3S--
MAILING ADDRESS 22- LC-L'c Cc) P/5-/_2 �IILI' l% 64111y /-Y A95 -2`%
PHL9M INTERVIEWED 5-f PC HD Ccmplaint #
Name & Relationship (i.e, owner tenant, etc.)
DATE TYPE FACILITY 3 'bit- EL2iZ1;zj, Paq,)6LC,:�
PROPOSED D ` :INSTAIJZR R&6-9(Z r Z19/40 y PHONE '739-2--R 2-5-"
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.
NP—Wr 0-UN6,'rION 13A M510/4/,Iii-0 FF-F-IDMA, R
1A1r-1i...'rA1+'roiZ1; 56-1- IN /7ft WA5U90 6-f?W6-1--
Proposal a. roved Proposal Disapproved
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Ins is Signa Ti e Pei kl r .. eZ Date t7 U De
fy ��
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 carponents tied to two fixed points (e.g.,house corners).
d. System description (e.g.,, 1250 gal. concrete septic tank,, three precast 61 diem. x 61 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 reportm— aggnt of owner agree to the above conditions.
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SIGNATURE TITLE P% qllq DATE
PIES: W-iite (PCHD); YeUcw (Ttkin HE); Pink LbRliawt)
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