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PUTNAM COUNTY HEALTH DEPARTMENT
cOGy DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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* PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
��' �' Y Q�� •� OFFICIAL USE ONLY
SITE LOCATION -3 �tckoa� TM#
OWNER'S NAME S O� rv� iv c. t ud Sad , PHONE ( O 7 f-
MAILING ADDRESS `)o. i 4f t t VA L LE JD .C2:F
PERSON INTERVIEWED PCHD Complaint #
ame Relationship i.e., owner, tenant, etc.
DATE � TYPE FAqy.4[TY
`�IPROPOSED INSTALLER 40 wj4Jk0 CSC AAestz r PHONE
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ADDRESS
.D u , )qA rA V A t-L,,e X t N ,,4 , .l; Jf?l REGISTRATION# j7e I : ,e
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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SIGNATURE TITLE �4-6 :apt DATE / C, / b 6 :!
Proposal approved with the following conditions: J `-'�' `"�"' �°
Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
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a. Owner's name
3.
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.
System repair to be
in accordance with the above proposal and conditions.
14-PiK 61 J 6�Lo r
's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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