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a,��'• -v�� PUTNAM COUNTY HEALTH DEPARDOR
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
* 225 -0310
�•. PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR _
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OKHMI S NAME PrLou I�G1 N b 111 PHONE
SITE LOCATION -�.j M W L s,'i. EVEW v p ug (c W H I DS21 To SMOT B-Lo 3
MAILING ADDRESS $ f Of &.0-F9
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER C t to a ojg M y t fi p�%o twA .q, 1 PHONE
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.
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Proposal approved Proposal Disapproved
Inspector's Signaturfi &
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roposal 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 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 own r re a ent of owner agree to the above conditions.
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DATE
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