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BOX 35
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PUTNAM OQUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME C Ana r, c"s S I �C6 I 1,nrl 0 PHCtNE J 2r -;3 U S—
SITE LOCATION ` nn•• TO
!MAILING ADDRESS ! 7 C , S �, t— :S't` .� �'t�f', Y� S / I 1 / �. 6 , On
PERSON INTERVIWED PC HD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER
PHONE
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.
—t; . Wr_pllm ?`-� \ /_ 6 � . , .0<�„ C'e,tp,
/ U ��Y1,1?.li/✓ �fiJ Ut. �— f VV 1� �_ .1 �i'! �/I.�/1,i -�. Cris �.-, i ,>t
Proposal approved
& T
Proposal Disapproved
Date
'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' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfomned in accordance with the above proposal and conditions.
T, as owner, or reported agent of owner agree to the above conditions.
TITLE DATE
OCP26: Witie ( ) , Yellow (Tam ED; Pink (Appli®nt)