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BOX 31
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PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME . . N tu'Q -S E , c 4Ai-v k o t c u PHONE
SITE LOCATION J t A-s a r2 A To
MAILING ADDRESS � F fc kS kJ(
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PERSON IlVTERVIEWED PCB C n:plaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE /Z� I q -I- TYPE FACILITY
Dim I4N Sliwa�;7
fL'I- to. Ltc 'V, tlS'
PHONE
Pro (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 approv Proposal Disapproved
Inspector's Signature Signature & Title Date
Proposal approved with the following conditions:
1. Procuremnt of any Town permit, if applicable.
2. Submisgion 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 carponents tied to two fixed points (e.g.,housse 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 reported agent of owner agree to the above conditions.
SIGNATURE :7 TITLE DATE
PIES: White MV; Yellow (fin ED; Pink Lzg2 iomt)