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83.16 -1 -19
BOX 30
1 AM
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IN
Pr (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.
�X►,SJ� /�cS /�S
X f `is J`, `-., T, is Z '
Proposal approved Proposal Disapproved
Date
proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2�. Suhmission 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 6' diam. x 6' deep
drywells 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 eported agent of owner agree to the above conditions.
SIGNATURE TITLE UM
3000.- *Abe (PW); YeUcw (T= ED; Pins (Ani icant)
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRON►MENIAL
HEALTH SERVICES
225 -0310
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W
,_. _ . ..= tic` J' S. aii" �FORPSE :��D�PO��.i- .��'E"�:•:.i�z'�.�• - == :�:;:.��,<w_
CARTER S NAME
�
SITE LOCATION
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MAILING ADDRESS
PERSON INTERVIEWED
PCHD Complaint #
19
Name & Relationship
(i.e, owner,tenant, etc.)
DATE �
9
TYPE FACILITY
PROPOSED -
PHONE
Pr (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.
�X►,SJ� /�cS /�S
X f `is J`, `-., T, is Z '
Proposal approved Proposal Disapproved
Date
proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2�. Suhmission 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 6' diam. x 6' deep
drywells 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 eported agent of owner agree to the above conditions.
SIGNATURE TITLE UM
3000.- *Abe (PW); YeUcw (T= ED; Pins (Ani icant)
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