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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION
OWNER'S NAME Ch,-1. o her cc rise A)
MAILING ADDRESS
OFFICIAb USE ONLY
TM# U 1S_--.2 - /S
PHONE S� 6 -3 760
PERSON INTERVIEWED uy'w soN J PCHD Complaint #
ame & Relationstlip .e., owner, tenant, etc.
DATE
TYPE FACILITY
PROPOSED INSTALLER PHONE,
ADDRESS
REGISTRATION#
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.
-¢� a, -o era c :reported agent of cwiiLr ab7ee to the condition's=stated on this' forrn�
SIGNATURE /.0 -- TITLE 0&) A-le r' DATE
Proposal approved with the following conditions:
I.- 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
s Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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