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BOX 31
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OWNER'S NAME _K0
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SITE IOCATION
MAILING ADDRESS
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PLTI'NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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_ PHONE
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 3 1 TYPE FACILITY E"(00k
PROPOSED INSTALLF'.R vv PHONE
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 fran.licensed professional engineer or
registered architect.
Proposal approved �. Proposal Disapproved
Inspector's SigratCee & Ti
roposal a roved with the following conditions:
1. Procurement of any Town permit, 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 cxinponents 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 agent of owner agree to
the above conditions.
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TITLE A-6 CWY T
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