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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIROMMIAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME
SITE LOCATIM
84AN«1k kAwoC ,�, PHONE SZ F EGG '
To
MAILING ADDRESS (5
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner tenant, etc.)
DATE f% 2 TYPE FACILITY S
PROPOSED INSTALLER PHONE 'S-
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.'
Proposal approved_ Proposal Disapproved
Inspector's Signature & Title
romsal approved with the followincr 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.
PIC
(e.g.,house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, I reported ag=ofowner agree to the above conditions.
SIGNATURE TITLE &CO� DATE ' Z
EMS: mite (MD); YeUcw Mtkm HI); Pink Lklliamt)