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OWNER'S NAME
SITE LOCATION
MAILING ADDRESS -
PERSON INTERVIE dMD
MAW=
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SE10M DISPOSAL SYSTEM REPAIR
PHONE
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ac.J AJ Pao Canplaint #
& Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY S OS
PROPOSED INSTALLER t) VL.14 i-J �� 1C C �\,- C , PHONE
REGISTRATION # ?�
Pro (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 fran licensed professional engineer or
registered architect.
Proposal
's
1 Proposal Disapproved
ture & Title
Y '
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 oorners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
dxywells 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 owner, or reported agen f er agree to the above conditions.
SIGNATURE TITLE DATE b
p16: W-dbe MV; YeUcw (Tom EL); Pink 041iaknt)