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04072
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04072
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PUTNAM COUNTY HEALTH DEPAR'Il4ENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES 1 8
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PROPOSAL FOR SEPAGE DISPOSAL ^'SYSTFM REPAIRY 1 E
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OWNER S NAME �1 r� 1 �f}fib v E2-D P A hLC pHC A 2,?
SITE LOCATION 13 o t4rw ITT Sr
MAILING ADDRESS Z,&(4C f�gsA (`r_ lIDL ,37
PERSON INTERVIEWED Pam Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER wfi-U PHONE 6i
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REGISTRATION #
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.
E xc�'rr .v 6 w e LL S.
Proposal approved • .. _ .. . :.
Inspector's Signature &
)roved with the following conditions:
Z Z >1g1
Date/
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 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.,.. ith the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE ,per /�% TITLE DATE '1/ ,V
PM: White (P ED); Yellcxw (Tan ED; Pink Lbg2 icent)