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03841
OWNER'S NAME
SITE LOCATION
PUTNAM COUNTY HEALTH DEPAE IMW
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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PHONE ��� 55 S�'I
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PEItS�1 IIVTERVIE WED PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.) _
DATE ✓ 1611-P *Y- TYPE FACILITY ( 3
PROPOSED INSSTAW�i PHONE <_ % —J 5
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 require submittal of proposal fran licensed professional engineer or
registered architect.
Proposal approved
Inspector's Signature & Tit
Proposal Disapproved
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 camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diatm. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. Systen,repair to be performed in accordance with the above proposal and conditions.
I, as owner 'or reported agent of owner agree to the above conditions.
SIGNATURE %� /,d�;� i�f ; �� TITLE LATE
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