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02744
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02744
101 'r r1u 401
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
/C C; r- ") 3
SITE LOCATION 9 L O tA G P- 10 e Tr—A1(_,. TM# 61,g—1
OWNER'S NAME tv►rr,5 C 0-W dP0 PHONE X52 —.-d,&0_6
MAILING ADDRESS N A- L 7
PERSON INTERVIEWED PCHD Complaint #
ame Relationship i.e., owner, tenant, eta
DATE TYPE FACILITY V`S
PROPOSED INSTALLER f/U ACO CA� PHONE Z 6 �S
ADDRESS C2 , l9SG�¢GV�4Vtl C �, REGISTRATION #_ _ L f
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.
as Qvypq _1.0.r reported agent of o er agree to the conditions stated �oyn this. form.:.: .
SIGNA TITLE DATE_�/
s roved mdth 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
e. Installers' name and number.
.3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
t Lo
pector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML