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04015
PUTNAM COUNTY HEALTH DEPARDOW
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME AQ /y//1 S , A,,e^..,1
Q, PHONE
SITE LOCATION A6 3 % , A, TO
MAILING ADDRESS
PERSON INTERVIEWED Pam Complaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE i S'- TYPE FACILITY
PROPOSED IN.STALI" Z JOC .,,mac. PHONE
REGISTRATION # (72-
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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ice,
Proposal owed
Inspector's Sicmature & Title
K_
G
Proposal Disapproved
Date
Proposal approved 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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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 TITLE �OATE
PW: V&be (PAD): YeUrow Mun BI); Pink (Appl mnt)
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
17 -
PROPOSAL FOR-SEWAGE DISPOSAL SYSTEMAkk
OMCLU USE ONLY
Rd 7Y-63
C.
SITE LOCATION AM 22M4,�Wlr- -- -- - .
OWNER'S NAME _PHO L 2S ZVI e
NE
MAILING ADDRESS 5 v u e
PERSON INTERVIEWED — PCHD Complaint #
Name & Rel anon nip owner enant, etc.T
DATE TYPE FACILITY —_SPS
PROPOSED INSTALLER cjHONE
ADDRESS e7- REGISTRATION#_,ef_2Z_
Z f.
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of sa;nq,,type as original sewage disposal system Different location
may require submittal of proposal from licensed professional engineer or registered architect.
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SIGNATURE
n TLE 4Q1-f 51 DATE
7
Proposal QDroved with the following conditions:
I 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 components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6'diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved if
Inspector's Signature & Title /ATE
COPIES: White (PCHD); Yellow (Town Bl); Pink (applicant)
PC-RP 99M L.