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04555
SITE LOCATION
OWNER'S NAME _
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
C-
�s-o4 09- h^ V4- G L
OFFICIAL USE ONLY
TM# ��' �5- / — yy
PHONE 5-2 1-3
PERSON INTERVIEWED PCHD Complaint #
Name & R a ations ip i.e., owner, tenant, etc.
DATE l0l'Z,7 Id) l TYPE FACILITY �k -`
PROPOSED IN$TALLE 0 u/ � " PHONE
ADDRESS &5C#fw$$t11q 0014E 4 Iii REGISTRATION# p C-
Prop o a (include sketch locating all adjacent wells): l 03 -W
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.
0
noo 6$� � -ck, �L�ck� � ✓�
I,. s owner`,. or xe,Iwrted agent 4 ovri* agree to the . ^oridItioris stated on this fo.* Iti — - -
i
SIGNATURE z
TITLE %TLS+ C&J'- DATE 2
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.
Proposalapproved ✓
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
DATE