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BOX 34
04452
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04452
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME A 1. ��-1 "Ct✓ Rim iL'�U C 1 PHONEZ
SITE LOCATION 4'L Le c&s �L4,w TO
MAILING . ADDRESS
PERSON INTERVIEWED PM Complaint $
Name & Relationship (i.e, owner, tenant, etc.)
DATE TYPE FACILITY
PROPOSED INST ' .. L` PHONE FL
_.... .
Proposal ( include sketch jocating . all adjacent wells.) :
NOTE: Repair must be in s&ae. location and of same type as original sewage disposal system.
Different location, may: require. submittal of proposal fram licensed professional engineer or
registered architect.
C-0 rgc N f
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approved
s
Title
I.
Proposal Disapproved
Proposal approved kith the followinct 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
Date
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.,
t
[, as owner, o r g " °er agree to the above conditions.
iIGI�1TIJRE TITLE DATE
US: V&te (POED) i Yellaw (ail ED; Pink QR2 i®nt)