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BOX 25
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03090
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRAI, HEALTH SERVICES
'225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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OWM S NAME -J4CQ lam$ b6y. y PHONE Sz (m - .Z ! C4
SITE NATION a 4 Jrjm> i L% _A 964;N PuTd/ m 1 41, _4j A1- y . TO 1 ` 2 - Va
MAUaW ADDRESS SAS
PERSON INTERVIEWED J"%J ss 1-evy ' Q%AN' Na91 PCHD Complaint #
'Name & Relations p U.,e, owner, tenant, etc.)
DATE _j 6 . So. 1Iri TYPE FACILITY
PROPOSED INISTA:= . S1 rXLDon4 GA . PHONE
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 Proposal Disapproved
Inspector's Signature & Ti a Date
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 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 er, ep
o or gent of owner agree to the above conditions.
SIG TITLE Oc%Aj�— DATE fps'
WW: WAba (MD); Ye11aw Data Ell); Pink (Aa2i,®nt) I
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