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BOX 32
04249
by AeP�'r-s .;,, P4.s�,s'�os
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL! SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION S- Aec ke p- 9T, TM# 9- 3 11V ° cl;�-" 15'a
OWNER'S NAME 4K 1. P,.. fA A 1 S c. , 4 PHONE R oZ 9
MAILING ADDRESS k- kf- BEE P-01-1111/1 /1 ti•e--S 3
PERSON INTERVIEWED PCHD Complaint #
ame a atlons Ip i.e., owner, tenant, etc.
DATE It I TYPE FACILITY
I 1
PROPOSED INSTALLER a- *6e&T— PHONE P-_-5-2-6
0,g(o psc w a�� (c . 1�t7
ADDRESS �r'T k 4� )A- c,L F Y IY � , REGISTRATION# � C 1 � �
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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.
NX k P. 1-6,C- F- VV e vim` ~ s'a -rv-e- A'1zs9
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as. owner; o re `orted agent of ovmor agree to then on itlons stated on thi. form:
SIGNATURE TITLE
rJ it DATE i" IS JO
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' diatn. X 6 deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Propo al approved
r's Si
DATE gnature &Title p
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
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