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PUTNAM COUNTY HEALTH DEPARTMENT
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PROPOS L. FOR SEWAGE 1?ISP.O$&L:,$YST9M REPAIR
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YANER' S NAME / % r� ! - .f"� , ��� /'t &J• ;
PHONE �,�
SITE LOCATION �o ti t�v' �4 . ,pC
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MAILING ADDRESS a' ' a' v' / ae !��` f !t i C C-
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PERSON INTERVIEWED
PCEID Complaint # `
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER J O NN 1 St L-efcA i
PHONE s' Z $ - E3 7
Proposal (include ,sketch. locating all adjacent wells):
NOTE:: Repair must be in same location and of same type as.original
sewage disposal system. f.
Different location may require submittal,of,proposal: fran licensed professional engineer, orCs;
registered architect.
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)roposal approved Proposal Disapproved
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Inspector's Signatur &Title Da
'roposal approved.with the following conditions:
1. Procurement of any Town _permit, if applicable. �t
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 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.
As owner, or reported ag of owner agree to the above conditions. r"
IGNATURE TITLE`' t` -'� DATE
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