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BOX 1
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PUTNAM.COUNTY..HEALTH DEPARTMENT
DIVISION OF ENVIRONMENIALAEUM MCI• MS
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Proposal (include sketch locating all adjacent wells):
NDM-; Repair must be in same. location and of same type as original sewage.disposal system.
Different location may require submittal'of proposal frai licensed professional engineer or
registered architect.
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Proposal approved f Proposal Disapproved
Inspector's Signature & Tille
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 corners).
d.: System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
dxywells 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.
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I, as owner, or reported a7 :;r of er agree to the above conditions.
4
SIGNATURE IQ TITLE DATE
MR& Write MD); YeUcw (fin BI); Pink (Ai2la3rit)
OWNER'S NAME ✓t/I.- -/ /'j'/r b 107T ".4 t.� f �5 �"'l -1 P
PHONE
SITE 1=TION !� �
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MAILING ADDRESS
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PERSON INTERVIEWED P
Pg1D Caoplaint i 7,6 a -
Name &
& Relationship (i..e, owner,tenant, e
etc.)
DATE / T
TYPE F
FACILITY
PROPOSED INS P
PHONE
Proposal (include sketch locating all adjacent wells):
NDM-; Repair must be in same. location and of same type as original sewage.disposal system.
Different location may require submittal'of proposal frai licensed professional engineer or
registered architect.
vY/!d Ale
t d! W v l z° oa le c.p /'" J`!7 <11, F� z/ ro C °7 ✓d d. G�, �z
ke
Proposal approved f Proposal Disapproved
Inspector's Signature & Tille
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 corners).
d.: System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
dxywells 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.
>r
I, as owner, or reported a7 :;r of er agree to the above conditions.
4
SIGNATURE IQ TITLE DATE
MR& Write MD); YeUcw (fin BI); Pink (Ai2la3rit)
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