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04042
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OWNER'S NAME
SITE LOCATION"
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PU NAM COUNTY HEALTH D►EPAR'Il�
DIVISION (1F' ,F,N�?IAL, FL'Ii�tETiCS `1 _
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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MAILING ADDRESS f oP--S 3 7
PERSON INTERVIEWED PW Catplaint #
Name & Relationship (i.e, owner,tenant, etc.) Q
DATE 5 1 0 0 TYPE FACILITY A�- IFS e
PROPOSED INSTALLER -I w aa-0 6 Q46 C a-T PHONE
REGISTRATION # C3
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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the following conditions:
Disapproved
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1. Procurement of any lawn pernut, it appiicaoi.e.
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 camponents 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
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in acoordan�e with the above proposal and conditions.
I, as owner, or reported agent of
SIGNATURE
PIM: W ibe (MV; Yellow Main ST); Pink 0924oant)
nr nn n17
the above conditions.
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