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SITE LOCATION ,
OWNER'S NAME_
MAILING ADDRES
PERSON INTER
DATE
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
5- RAP . TM# 7 V, I
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PCHD Complaint #
ame k. RelatinnOin i i_e__ owner. tenant etc.
PROPOSED INSTALLER J-4jda/ &N19 (��,
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ADDRESS it;a;_Lc it . &i
TYPE FACILI ;Y . K 6 S
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REGISTRATION# PC. / 3 �
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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I; as owner,
SIGNA
of owner agree fo'the conditions itated oa this form.
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TITLE ;TTY �� .r
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be rformed in accordance with the above proposal and conditions.
Pro osal approved
pector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 9ME
DATE
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