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91.32 -1 -30 & 91.- 32 -1 -31
BOX 36
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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SITE LOCATION
OWNER'S NAME_
MAILING ADDRESS
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
TM# 3
PHONE S;t�? -S- I l e
PERSON, INTERVIEWED PCHD Complaint #
J ame & Relationship (i.e., owner, tenant, etc.
DATE.�.��, /T = TYPE FACILITY 6?r-S
PROPOSED
ADDRESS
REGISTRATION# PC 13
Proposal (include sketch locating all adjacent wells): 0. &4 V
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.
e,
I, as ow, ner o reported agent of owner agree to the conditions `stated on this form.
SIGNATURE TITLE 66e-"e ,; DATE e a
Proposal approved with the following conditions: t, " l
1. Procurement of any Town permit, if applicable..,.*,
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 &,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 ormed in accordance with the above propo'Sa1 and conditions.
Proposal approved
pector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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