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BOX 36
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PUTNAM COUN'T'Y HEALTH DEPARTMW
DIVISION OF EWIRIONMENIAL HEALTH SERVICES
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~ PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
- ` POE Cam' S NAME Z-i` "q.14F
SITE LOCATION L14 L cZ TO 5/12-4
MAILING ADDRESS
i
DATE
PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
44-6 CA57,
PHONE S' LC r-AS 1 Sr
REGISTRATION # (3R,
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 aWr'o,�jed 4
Inspector's -Signature &
Proposal Disapproved
Proposal amroved 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.
Date
c. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' sleep
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.
I, as owner, or reported agent of owner agree to the above .
conditions
SIGNATURE TITLE 46 C"C e-1- DATE 6 �b
OV
PM: Mite MV; Yellow (in ffi); Pink (Aniicent)