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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
3 36 r7 -0a
SITE LOCATION C1 - �/� F 'u -r (� uo k TM# 7,� , 19 -- 1
OWNER'S NAME \,U t LL I f9r - P -Ai1e( PHONE ^ 6 69 i
MAILING ADDRESS )ul ,7-4
PERSON INTERVIEWED PCHD Complaint #
ame a ations p i.e., owner, tenant, etc.
DATE I 'v TYPE FACILITY R <6S
PROPOSED INSTALLER O 6t'z,14-6f-A1-r1—PHONE 5 ,46 '
C-X( (0 VS
ADDRESS 14* 103 -2 REGISTRATION# PC i 8
P=osal (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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I, as owner,' o reported agent 'of owner agree to the conditions stated on this form. -
SIGNA �i.;U TITLE DATE-' V17 O `—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_____
Inspector's Signature & Title ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML