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03751
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION_J
OWNER'S NAME_
MAILING ADDRES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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PERSON INTERVIEWED PCHD Complaint #
—Na-ime & Relationship (i.e., owner, tenant, etc.
DATE
_TYPE FACILITY
_PHONE � ��✓ ��
ISTRATION#
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 rewiirf mbmittal of proposal. from licensed professional engineero registered architect.
-,-as* o er; o r orted Z�icwner agree to the conditions -stared on'd -iis form. 2 " +
SIGNA QS TITLE I�l %� DATE v
5,
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 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 performed in accordance with the above proposal and conditions..
Proposal approved
Inspector's Signature & Title ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE