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PUTNAM OOUNTY HEALTH DEPARTMENT AY 105 W
-DIVISIMP _E IRONME
225-0310
PROPOSAL FOR SBOM DISPOSAL SYSTEM REPAIR
amm's, NAME d- Vo R I" CPA la AA I ffo PHONE
SITE iwmw *2-o eblest Kv r S TM D.33 zf=
MAILING ADDRESS k-AkC
DATE
I * 51 IN 4zC9 0 in is 519,
Pam) Cam)laint #
Name & Relationship (i.e, rwnar +-,armn+- etc.)
TYPEFAciLny
PHONE
M
Ca C
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.
J,
too 0
WA,
(r-
Proposal approved
Inspector's-Signature &
Proposal Disapproved
L I Date
I
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 Nam, Town and Tax map number.
C. Location of installed carponents tied to two fixed points (e.g.phouse corners).
d. System description (e.g., 1250 gal. concrete septic tank,, three precast 611diam. x 61 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.
I,, as owner,, or reported agent of owner agree to the above conditions.
SIGNA, A19? q,444, -
TITLE DATE
I 1UN: WA be (PCHD); Yellow Mkin ED; Pink Qqliamt)