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PU!'NAM COUNTY HEALTH DEPARTMENT
DIVISIONT OF ENVIRONMENTAL HEALTH SERVICESn (�
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
:: owNER's NAME t-2 V 1�,6,e �� 10 PHONE ,5�2
SITE LOWION ` v1 O hAl SnAJ :ST L't P-,-,�S C.;, u. m# 91�i7..
MAILING ADORES$ S l'YI Ci_S f-t �, y V P 1 ( 316 6 05f Y Z �
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE v S 1 TYPE FACILITY 5
PROPOSED INSTALLER hp- 2.o t,J ftC- A v p j , h 15� . -Z 1,-C • PHONE "' I L L- a0 D
REGISTRATION # )•Z .. 4-1 404/
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.
p�s rrC Propcwf7
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Proposal approved / / Proposal Disapproved '
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r s Signature & Title Date
cate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed camponents 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.
(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, or reported agent of owner a ree to the above Lnd7itions.
TITLE
PAS: Wifbe MV; Yellow (nth EI); Pink (Appticant)
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