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03291
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1 PUTNAM COUNTY HEALTH DEPARTMM
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 - 3838/225- 3833/.225 -3641
PR0 O,� - 'OR "`SEWAGE' DISPOSAL SYSTEM-REPAIR':':
OWNER'S NAME �. rS y U•7 0 O PHONE
SITE IDCATION rim#
MAILING ADDRESS
DATE
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R Oev ova PCHD
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
int #
PROPOSED ' INSTALLER �1 vl -1 (±� �I(r� P ✓ f PHONE S �2 67/-/,f
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.
41
Proposal approved _7L�
r( .
`� V1
Inspector's Signature &
Proposal Disapproved
conditions:
i'L(j ULMI=11L UL Glil_/ -LUW11 it Gi�J�Ji 1 \.ca4l�c.
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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
A Sure�c►JU va q, W �•a / d w v;,d
Ao &, t v✓�F,�.cw,x�� LUG.
Da
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be perfomed in accordance with the above proposal and conditions.
I, as owner, or reported a ent of owner agree to the above conditions.
SIGNATURE - TITLE 401flk DATE
S: WAte MD); Yellow 030 RC); Pink Lkliicant)
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WK
I
41
Proposal approved _7L�
r( .
`� V1
Inspector's Signature &
Proposal Disapproved
conditions:
i'L(j ULMI=11L UL Glil_/ -LUW11 it Gi�J�Ji 1 \.ca4l�c.
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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
A Sure�c►JU va q, W �•a / d w v;,d
Ao &, t v✓�F,�.cw,x�� LUG.
Da
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be perfomed in accordance with the above proposal and conditions.
I, as owner, or reported a ent of owner agree to the above conditions.
SIGNATURE - TITLE 401flk DATE
S: WAte MD); Yellow 030 RC); Pink Lkliicant)