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BOX 24
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WIN 0 IL
02798
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE liISPOSAL SYSTEM-REPAIR
OFFICIAL USE ONLY
SITE LOCATION 62
OWNER'S NAME v
MAILING ADDRESS_L
PERSON INTERVIEWED_
DATE �- /
PROPOSED INSTALLED
ADDRESS
�?0 4✓ y
ul TM#
PHONE
PCHD Complaint #
TYPE FACILITY
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.
/4-5
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I., as owner, _ .reported aAnt of owner agree to the conditions stated r� this fcr-n.
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 components tied to two fixed points (e.g.,house comers).
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_
Inspector's Signature & Title
A
COPIES: White (PCHD); Yellow (Town BI); P' , applicant)
PC -RP 99ML flu-,