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03292
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03292
SITE LOCATION
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PUTNAM COUNTY HEALTH DEPARTMENr
DIVISION QF- ENVIRONMENPAL, .HEALTH_ SERVICES -
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225 -0310
PROPOSAL FOR SEXkGE DISPOSAL SYSTEM REPAIR
C n3 PHONE
I PAID Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PHONE
C A7
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
Inspector's Signature &
Proposal Disapproved
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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 owpe re agent f owner gr'eeo the above conditions.
SIGNATURE e- TITLE
PBS: V&te (PAD); YeUcw (Tam ED; Pink 042103nt)
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