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03819
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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SITE LOCATION ti ) / , 11 i �i�t / l/�
OWNER'S NAME ti F PHONE —G L
MAILING ADDRESSV73 I a i.i
PERSON
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(IEWED �4 n S PCHD Complaint #
ame &RetKionship i.., owner, tenant, etc.
W TYPE FACILITY
PROPOSED INSTALER��, PHONE
ADDRESS A ? � -W, / y 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 requ,�e sVbmittal of proposal from licensed professional engineer or rS gistered architect.
I, as owner, or
of owner agree to the conditions stated on this. form.
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 b. a per /formed in accordance with the above proposal and'conditions.
Proposalapproved v
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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DATE
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SITE LOCATION
OWNER'S NAME_
MAILING ADDRESS
PERSON INT R IEV
DATE
PROPOSE STALI
ADDRESS A ? )
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM PAY
OFFICIAL USE ONLY
r
PHONE --G
` 11 //
_PCHD Complaint #
TYPE FACILITY
1'1. 11_.
[RATION#
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 re u- a s mittal of p7opo from licensed professional engine r or regis ed architect.
iex,;:or- oited. ent of owner agree to the conditions 9tated'on this:fvrm. J.
SIGNATURE TITLE �_ DATE /
Proposal a rov with the followin 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 b. a per /formed in accordance with the above proposal and conditions.
Proposal approved v
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML