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BOX 2
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PU NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME A _ h a k' r, lC e 2 PHONE C76 '230(,
SITE LOCATION / v --I 0? ? -t- 3 / / .-S o 1:3 TO
MAILING ADDRESS n,-2 0 7 t I( 7�, r -S o ,r—S
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE °' //i- q& 0 NO TYPE FACILITY
177••.1
PHONE
REGISTRATION #
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.
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Proposal a r ed Proposal Disapproved
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InspEfcWr s Signature & Title Date
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' 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.
I, as owner, or reported agent of owner agree to the above conditions.
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SIGNATURE Z,� LjZ.�v'� -�- C' ' -
IP1FI : Wiite (P HW; YeUc w Umn HU; Pink (AFpUcant)
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