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PUTNAM COUN'T'Y HEALTH DEPARTMENT 0(,
� 611-7
DIVISION OF ENVIRWIENrAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER Is NAME l7a y «P A 9 y-a yo c PHONE it q- 52r. 1*
2 61 Zq o 6
SITE LOCATION ;4`3 140 J 21I d . P t-ham . Valley MK#
NG
MAILI ADDRESS fi' O. �X L4 77 --5h v U b G , N V 1 a S-8 &
PERSON INTERVIEWED PCHD Complaint.#
Name & Relationship (i.e, awner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER w4 V-4 i so (f r t 7'`P -ez c.,'O YS PHONE 73 6 - To 10
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 fray licensed professional engineer or
registered architect.
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Proposal
's Siqnature & Title
Proposal Disapproved
Date
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 canponents tied to two fixed points (e.g.,house corners).,
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam.
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.
x 6' deep
I, as owner, or reported agent of owner agree to the above conditions.
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FORMERLY "AuTomATED 60S. APPLICIf-TION
TAX MAP s-4 -,)L -s
P07N,9R VALLEY
f•tnam County Departatint of Health
Division of Environmental Realth Servioes
Approved as noted for conformance with
aPP)izab3c Fules and Eegulhticns of the
P am Count alth Department.
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AS B UILT SOA
FORMERLY "AuTomATED 60S. APPLICIf-TION
TAX MAP s-4 -,)L -s
P07N,9R VALLEY
f•tnam County Departatint of Health
Division of Environmental Realth Servioes
Approved as noted for conformance with
aPP)izab3c Fules and Eegulhticns of the
P am Count alth Department.
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Title, Date
s.