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03082
i D PUTNAM COUN'T'Y HEALTH DEPARTMENT'
! DIVISION OF ENVIRIXZENAL HEALTH SERVICES
225 -0310 .A96
_ PROPOSAL _FOR SFWAGE _DISPOSAL ,SYSTEM
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OWNER'S NAME � o /w A s J OA � �S PHONE to g y�
SITE LOCATION o IL,-/ Ea 5 CA - O M/ d i k� .t
MAILING ADDRESS (.t. N I l I- A. R D 4 A /ec Ox CA c; AM A 10.r?
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PERSON INTERVIEWED PCHD Complaint #
Name at Relationship (i.e, owner,tenant, etc.)
DATE V ,� �_� r; ,P TYPE FACILITY
PROPOSED INSTALLER A P-A x k oey 5' rA yc rlo. j PHA
oMF_
NE
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 <approvedT Proposal Disapproved
Pate
Voposal 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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywalls surrounded by one" t +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 gent of owner agree
SIGNATURE
PBS: *Ate (PG); Yellcow (Tapin HE); Pink (AF21amt)
to the above conditions.
TITLE A- c�� DATE / ee