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02822
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PUl'NAM COUN'T'Y HEALTH DEPARMENT
_ DIVISION OF . ENVIRIONMEML HEALTH SERVICES
PROPOSAL FOR MaGE DISPOSAL SYSTEK REPAIR
OWNER'S NAME d24V1 0 o L M W-1 PHONE 6-24
SITE LOCATION / '7 dz-Coc * d T vR To ill
MAILING ADDRESS P1 v- v 0#)ft VAGcxv IV V, L -o 3
PERSON W VIEWED
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REGISTRATION # �
(include ske ch locating all adjacent wells):
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PHONE L2 G oZ 5 7 f
NME: 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 ox
registered architect.
Proposal
Proposal Disapproved
ture &
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 camponents 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
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 reported agent of owner agree to the above conditions.
SIGNATURE W TITLE DATE
OO .S: Wiitie (POD); Yellow Mim BI); Pink MRAicant)