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03355
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PUI'NAM OOUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME
SITE LOCATION 10' G' C )a' r, (Z R `' -A N r—
MAILING ADDRESS1*6 C�9. R G�AHP --
PERSON INTERVIEWED
�v Name & Relationsh:
DATE !�' i
PROPOSED INSTALLER ® G f R HeA 0
PHONE 52- Cam- Lg
U1'1,iA- p���GFy Ala' t
PCHD Canplaint #
Lp (i.e, owner tenant, etc.)
TYPE FACILITY tj 1� PR G- -
PHONE 73 ci-" O J ..
REGISTRATION #
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
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& Title
Proposal Disapproved
Proposal approved with the following conditions:
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
&. /
Date
(e.g. house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above I proposal and conditions.
I, as owner, or re errs owner agree to the above conditions.
SIGNATURE TITLE ,() &oot/4 '4 DATE I ( 3 v
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PM Waite (POD); Yellcow 03m ffi); Pink (AgUcw t)
wad, Nol-110JV
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