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03104
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIROIZNTAL HEALTH SERVICES
2n5-3938/225- 3833/225 -3641
PROPOSAL FOR SEPg1GE DISP04AL 'SYS fA RkPA1R "..
SITE LOCATION ���_ ��fi�i9G7.s1 YTX�1„ L/ALLry JS/ (r TM#
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
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 subrm � i censed professional engineer or
registered architect. �) ^ -� j
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Proposal approved
Inspector's Signature
with the
Proposal Disapproved
conditions:,,
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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," ints (e.g.. hous e 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.
i14
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE ���� TITLE
IPgS: W to MU); YeUcw (Tom ffi); Pink (AR11aknt) `
DATE