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.a rUiNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME ;REBECCA tArVLIIAIAA 0 M. "O, PHONE
SITE LOCATION i �v a Wc5-r Sr4dKt -J>R TO
MAILING ADDRESS 1� We6r SOV99 � ��T�ihw. UALi�v NV .
DATE
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ant, etc.)
TYPE FACILITY
6a6 -agSy
Camplaint #
30-Nr4 3 co�35 PHCNE(91 ) 526 - 2•-Z %,�
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.
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Proposal approved
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Inspector's Signatums
Proposal Disapproved
Date
roposa. 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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam.
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.
s owner, or reported ent of agree to the above conditions.
SIGNATURE TITLE DATE
ERES: White ( ; W1aw a EI); Pink LbAi mnt)
x 6' deep
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