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BOX 2
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SITE IDMTIM
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MAILING ADDRESSv�nQ,
PERSON INTIItVIEWW PCHD Complaint #
:.Name & Relationship (i.e, owner tenant, etc.)
DATE TYPE FACILITY
PROPOSED DWALUM 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.
1411 WE
Proposal approved _� Proposal Disapproved
roaosal aocroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
d
to
(e.g. ,house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or; agent owner agree to the above conditions.
SIGNATURE ,� 4 TITLE
MMS: White (MV; Yellow (fin BI); Pink LkTU®nt)
PC -RP 97
J yO
GATE /
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
R I Q 7—o
SITE LOCATION Ir S+�� -!�i S)t- ,- s11tel -svX1 TM#
OWNER'S NAME 13nza in 4A L PHONE
MAILING ADDRESS Sy ra
PERSON INTERVIEWED (1w7-11 PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
DATE l TYPE FACILITY
PROPOSED INSTALLER Qymz, 6:.,u 144- PHONE 3'ys'- P:r- 2.) -7.3
ADDRESS )T 1-e If-,V REGISTRATION# PG fy/
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.
I, as owner, or reported agent of owner agree to the conditionss� stated on this form.
SIGNATURE TITLE-
'ell7'���
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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
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE