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BOX 32
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04213
PUTNAM COUNTY HEALTH DEPAR24M
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SE4AGE•.DISPOSAL SYSTEM.REPAIR
OWNER'S NAME
SITE LOCATION
MAILING
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
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PHONE 'FIV- Z S'.- !3
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. (' /� (� r
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Proposal approved Disapproved
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Inspector's Signature & Xtle Date
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.
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 with the above proposal and conditions.
I, as owner, reported agent of owner agree to the above conditions. p
SIGNATURE TITLE fe.5 . DATE � 34 0
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