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BOX 34
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Name & Relationship (i.e., owner, tenant, contractor)
j - �-- 01 FACILITY TYPE Re-5) Je4ce PCHD COMPLAINT #
PROPOSED INSTALLER .1e -I-Z/ 116 Lj e- PHONE #
ADDRESS 3 �r.�d SgSi Lq.9A PU` U� / %Q�! REGISTRATION /LICENSE # _Pr ^,J
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE:- The Department may require submittal of proposal from licensed professional depending orl the_
I, as owner,agree t the conditions stated on this form
SIGNATURE TITLE �.�n. DATE
(owner) I
I, the septic installer, agree to comply with the onditions of this permit for the septic system repair
SIGNATURE TITLE DATE y g
(installer) '
Proposal approved with the following conditions: _3
1. . Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
L`I V ;l 41*IZI 1
Proposal Approved Q Proposal Denied ❑
nspector's Signature & Title Da a Expiration Date
Repair proposal is in compliance with applicable codes Yes Ar No O
COPIES: , PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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