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04222
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
�TW OFFICIAL USE ONLY
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(DATE. TE LOCATION S TM# .3 t 8 0 -1-5P S
WNER'S NAME V ! 't05 PHONE S� �- 6!&
AILING ADDRESS 1�� (� P-E�� 6
ERSON INTERVIEWED PCHD Complaint #
ame Relationship i.e., owner, tenant, etc.
TYPE FACILITY ��S
ROPOSED STALLER L�/t 1 PHONE 6'Z6
W 6 05col wv4 -1V A lq- Q' REGISTRATION#
ADDRESS rn. w , n_� P�.r� 1 3
Proposal (include sketch locating all adjacent wells j:
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal o,�fsroposal from licensed professional engineer or registered architect. l
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SIGNATURE TITLE �G � � DATE 2! 6..?
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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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