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04714
PUTNAM COUNTY HEALTH DEPARIMEIJP
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SBiAGE DISPOSAL SYSTEM REPAIR
23 98'
OKWM I S NAME �C'� k P 1 eA SO pV PHONE `UO
SITE LOCATION 1 �.3O� 4 e.— s - TO
MAILING ADDRESS
U.
DATE
.-A -C- PCHD Complaint
ant, etc.)
TYPE FACILITY
PROPOSED INST Kg nL D L1[.C. Sr�t PHONE 9I 'A'1-tQ_ -0500
I
(include sice�� 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.
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Proposal ap�r��ad
18 ,
's
with
Proposal Disapproved
& T'
following conditions:
Date
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 camponents 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
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of own Tee to the above conditions.
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.SIGNATURE TITLE t It DATE
PBS: Vtdte MD); Yellow (fin ED; Pink (Anliamt)
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