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PUl'NAM COUN'T'Y HEALTH DEPAWMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-.2725"031-0
PROPOSAL FOR SMUM DISPOSAL SYSTEM REPAIR
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OWNER'S NAME ice% ry; s G 13 ,r,4 4A - PHONE Sa *• /
SITE LOCATION !V2 Gil h tri .4n. G Aur v aw4 l/.4niq n& y,, TO
MAILING ADDRESS .E,4
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER CAP,,y a L d Coo" 7- C tv. PHONE
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.
/ ? Ti'C- .Sti.S i e,—!
Inspector's Signature &
Proposal Disapproved
n.
Date
toposal 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 corners).
. Stem de p
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
L, as owner, or reported agent of owner agree to the above conditions.
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CANOPUS CONSTRUCTION Co
233 CAffqOFUS HOLLOW R--
P, V. gyf 10579
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE �DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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SITE LOCATION- ?0 -4;,r7 V -d I te--�_f TM# - -- i — 16
OWNER'S NAME f3,,,.,4 dl , PHONE M-- TJ 4P'- 1-3 Y.7
MAILING ADDRESS 6;-1 U e ,,i
PERSON INTERVIEWED PCHD Complaint #_
ame & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER �. r,, �,a t.�s.,i �G' ?. PHONE/
ADDRESS „2,33 c.�-G ,,,es REGISTRATION# 3S�— 61 Y
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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SIGNATURE, TITLE DATE��
Proposal approved with the following conditions:
I. 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
/P a
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s Signature & Title ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NIL,
U-71
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