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PUTNAM COUNTY HEALTH DEPARIMENT
DIVISION OF ENVIRONMENTAL HEAD LTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM
REPAIR
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OWNER'S NAME Lo w5 M4 zz-A
PHONE 2 5 7
SITE LOCATION If A"Vcdc 03
MAILING ADDRESS o -5-,T7
PERSON INTERVIEWED PCHD CaqDlaint #
Name & Relationship (i.e, owner,, tenant, etc.)
DATE YZI TYPE FACILITY
PHONE 2- of g9 5'-
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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77Z A Proposal Disapproved
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Proposal approved with the following conditions:
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1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
*ilg..house corners).
a. Owner's name.
b. Site Street Nam, Town and Tax Map number.
c. Location of installed components tied to two fixed points e.g.,,
d. System description (e.g., 1250 gal. concrete septic tank,, three precas t 6' diam. x 61 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.
as owner, or reported gent of owner agree to the above conditions.
SIGNM TITLE DATE
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S\: Mite (PCHD); YeUcw (Tam HE); Pink (Aniiamit)
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9145262595 GRAGERT CONST 031 P01 MAP, 12 193 23:35
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