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04132
PUTNAM COUN'T'Y HEALTH DEPART
.. _ �J�� ="T� -� iD� .; ENVIF�ON�A�,,: FH•��?'H.. .�C�:
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME c k CA ud rW I bxa,4 C R 0 Z
SITE LOCATION P c, %,N-V N►ofL ,,
PHONE
TO
MAILING ADDRESS ►► �o �.. to a r �-�. TZ n _ v x� 1 _i,��
PEA INTERVIEWED GAS 1,,0..,.� V (f_vz v'Z PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE y _ r) 4 -2 TYPE FACILITY
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type a
Different location may require submittal of proposal fran
original sewage disposal system.
licensed professional engineer or
._.G/'� /.�"'%1�GG- •G�E�E/ �OC�c, GAD / /C.c/' G'or/c�/z��•("—c�•r 7/�.[/.�
Proposal approved
Inspector's
Proposal Disapproved
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.
i' Date
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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 own agr to
SIGNATURE`-�"''� /�
IPgS: White MD); YeUcw ( ); Pink (kV io3nt)
the above conditions.
TITLE DATE