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03861
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PR�I�OSA7;" 'OR SEWAGE -bjfq ',gkg REPAIR
5-2- If
OWNER'S 17M 19-avA ► Cq AG L- EA, PHCNE__
SITE LOCkTIO T-CE TO
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MAILING AD22 6 1, 96 ? +41. ANC-1 /051d
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner tenant, etc.)
DATE 11W Lid TYPE FACILITY
.
PROPOSED INSTALLER Ww" Aridw.Pul PHONE _ 40
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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roposal approved
Proposal Disapproved
Proposal awroved with the following conditions:
to
1. Procurement of any Town pemit, 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).
d. System description (e.g.,,1250 gal. concrete septic tank, three precast 61 diam. x 61 deep
drywalls surrounded by one foot + gravel).
e. Installer's name and-number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to tFleabove conditions.
SIGNATUREqJLW TITLE . DATE Or
14 — _7 I
JPTES: V&te (PCHD); Yellow (tn El); Ph* (An2icmit)