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04749
r
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME Y `0
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PHONE
SITE LOCATION
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To
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MAILING ADDRESS
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PERSON INTERVIEWED
PCHD Canplaint #
Name & Relationship (i.e,owner,tenant,
etc.)
DATE
/
J� 1 TYPE
FACILITY
PROPOSED INSTALLER
Me. :,v Ali' fin. %
PHONE
'S"9CS"r
REGISTRATION # J- 7r,
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.
C / IW I- I- 0 r -, -T/d A'
's
& Title
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 performed in accordance with the above proposal and conditions.
7
I, as owner, r reported agent of owner agree to the above
� conditions.
SIGNATURE --
DATE 0-/J (o
.. & Wdbe MV; Yellrcw abwn BI); Plink (k#iamt)
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W V 'VY
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL. FOR SLWAGL DISPOSAL SYST)
RE
OFFICIAL USE ONLY
SITE LOCATION 3 � L P� � � TM# � �� 2 3S'
OWNER'S NAME P PHONE _'Z8 -- 6 Y 39
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE �k 191t. a(. TYPE FACILITY 90-f
,PROPOSED INSTALLER r tfJ�'� PHONE
ADDRESS D40 PA-9 Pv'r�rrvW pt(,a q REGISTRATION#
Proposal (include sketch locating all adjacent wells): (Q4,
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.
I, as owner, .- °ported agent -of owner agree to the :conditions stated on: his fortr.
SIGNATURE TITLE
('�O� DATE P I Z'
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
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 ' 9.9M L.