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PUTNAM COUNTY HEALTH DEPARTMENT O W/ O 0
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME ,?,non &ncd %-I- PHONE
SITE LOCATION 3 - /72.; 7W p /%r o.► 1 63 To `" a
MAILING ADDRESS Sync .
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 7-)-7-,Pc TYPE FACIILITY h Mt.
PROPOSED INSTALLER „ -QA4#;
REGISTRATION #
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original
Different location may require sutmittal of proposal fram licensed
registered architect.
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PHONE 9111- �s 373
sewage disposal system.
professional engineer or
`e A.) &§ J-4 4 ".1
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Proposal approved Proposal Disapproved
Inspector's Signature & Title
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
drywalls 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 I 4��/ TITLS DATE
PM: indite (MD): Yellow /Min ED; Pink (Appliamt)
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