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BOX 30
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03895
OWNER'S NAME
SITE I=TION
MAILING ADDRESS �Ce
PERSON. INTERVIEWED
DATE 1� 3- L
PROPOSED INSTALLER
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENAL HEALTH SERVICES,. _
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
6> F T r PHCNE /C� -S8 -373
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& Relationsh' (i.e, owner,tenant, etc.) f�
TYPE FACILITY
L COAJ PHONE S
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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Proposal approved
.......... .
Inspector's Signature &
Proposal Disapproved
Proposal approved with the followincz conditions:
1. Procurement of any Town permit, if applicable.
2. Submis .1ion 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
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(e.g.,house corners).
three precast 6' diam. x 6' deep
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 lT agree to the above conditions.
SIGNATURE TITLE DATE
IM: White (PCED): YeUc7w Mkm ED; Pink Lk#inant)