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02791
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02791
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARZMENr
DIVISION OF ENVIRONMENTAL HEALTH SERVICES -
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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TO
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE ,5 / TYPE FACILITY �S
PROPOSED INSTALLER 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 from licensed professional engineer or
registered architect.
_ _.. � 7S%'�'�/ �p/ a! � �i `ate -..ems j ��1 � %✓S' l� �—`'- �--
Proposal approved �—
Inspector's
& Title
Proposal Disapproved
Proposal approved with the followincr 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 camponents 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.
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(e.g.,house corners).
three precast. 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
as owner, or re rted agent of owner agr to the above conditions.
;IGNATURE TITLE DATE
OrS: *Ite (PCHD); Yellcw (Tvn ED; Pink (Applicant)