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03037
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$ITE LOCATION
OWNER'S NAME_
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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4- RARIL id . _PHONE
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE �I 3 �� TYPE FACILITY
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PHONE
TRATION# 13k"
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PROPOSED INSTALLER ilftd f) WRI 02
DRESS,% n5ct Rd PV �y,4J/
Proposal (include sketch locating all adjacent wells): 4
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require su ttal of proposal from licensed professional engineer or registered architect.
16.1 , /ige-6 rlq.t _ r C /k2e--, rq 4" &- X4
h- a&o.�yner;o reporte&agent of owner. agree to the conditions stated.owthi&form.
SIGNA Z41 0 TITLE DATE 7 -� % 't
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 /Z><—
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML