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04125
PUTNAM COUNTY HEALTH DEPARTMENT
D1VISI(:`OF MWIRONMERrAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAM M9 4--m c" ' s y i- i" K R 455.5 �A- PHONE 5 2-Zg
SITE LOCATION /.- P T D -R . r s 41<-r- To i
MAILING ADDRESS
PERSON INITERVIE
7LA6gPeC7- 6SC4 -wAsv*-
PCID Complaint #
Name & Relationship (i.e, owner tenant, etc.)
Z. TYPE FACILITY
t-u
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 from licensed professional engineer or
registered architect.
Rg' i&de
49 e% i A
Proposal ov Proposal Disapproved
_f
Irli or's Signature & Title
'ro222:7approved with the following conditions:
1. Proarement of any Town permit, if applicable.
2. Su0✓ri.ssion of as built repair sketch in duplicate showing:
a. arner's name.
b. ite Street Name, Town and Tax Map number.
c. ])cation of installed ccmponents tied to two fixed points (e.g.,house corners).
d. Vsten description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
Qywells surrounded by one foot + gravel).
e. installer's name and number.
3. SyYsm repair to be performed in accordance with the above proposal and conditions.
I, as o3er, or reported agent of owner agree to the above conditions.
SIGNA XE A;&--�7 TITLE -4614CIgl-- DATE
RTES: woe MV; YeUcw (inn ED; Pink Gg l.iamt)