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CWNER' S NAME L, U I
SITE LOCATION
MAILING ADDRESS_ L
PERSON INTERVIEWED
DATE �It kh
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PUTNAM COUNTY HEALTH DEPARDOW
DIVISION OF MURMMUAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REMIlt1
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PHONE
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PW Canplaint #
(i.e, owner,tenant, etc.)
TYPE FACILITY
PHONE CJ 2 h..... -o7S�:l,-
REGISTRATION # 13y,
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.
Proposal approved �/ 1 A Proposal Disapproved
v �
s Signature &
with the
conditions:
V11f
Date
1. Procurement of any Town permit, if applicable.
2. Sub=mission 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 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, reported agent of owner agree to the above conditions. G
SIGNATURE TITLEifd'C� DATE l T
PIES: Hhite (PaD): YeUc w (fin BI); Pink (Anilmrit)