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BOX 25
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03015
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PUTNAM COUNTY HEALTH DEPARTMENT AV r'>9
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SWM DISPOSAL SYSTEM REPAIR
OWNER'S ,NAME 4r PHONE
SITE LOCATION _Cn AI A_ Le Is C- T, 7M#
MAILING ADDRESS
PERSON INTERVIEWED PCHD Caqplaifit #
Name & Relationship (i.e, owner tenant, etc.)
DATE TYPE FACILITY pa's
PROPOSED INSTALLER fi�f-aAm 6A,!2cA&z:-- PHONE 5;;16 -.2- S-9
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. C, /+ FC k- rEY-vr-PjAZ6 -5v-sr-,--A1 '-o A- t(ock",q-
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Proposal Disapproved
Date
'rpposal approved with the following conditions:
1. Procurement of any Town permit, applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner I 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 61 diam. x 61 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, o reported agent of owner agree to the above conditions.
SIGNATURE TIME ar" DATE du A6
PM: V&te (KED); Yellow (2kin E01); Pink Qqilcmit)