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1.16 r
04717
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION ` "t V O-T Ef " S
OWNER'S NAME 8PLlya.L4 Z 61
MAILING ADDRESS /<e- W F t ,-5,'(--, (
OFFICIAL USE ONLY
R
TM# 51 V) 5 I— S R,
PHONE 54r f-i- -Y 5'32S'
PERSON INTERVIEWED PCHD Complaint #,
_ Name & Relationship i.e., owner, tenant, etc.
TYPE FACILITY 144- S
DATE &/ 1 /0 z
PROPOSED INSTALLER. �v F)- Q 9 UCc 4 & 4 (If PHONE S a 6 —o? S--q S
O Sc6 w A N A d
ADDRESS P� �-r�� U�4 c �y ��.C7�, lof?SREGISTRATION# 'F� �- (3f
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.
_ - ..... as nwner; _ r reported a ent of owner agree torthe conditiormstaftAo -q. this, form. -
SIGNATURE . LI'v4"t k TITLE
Proposal 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
DATE l JOLI
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.
Proposal approved-
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML