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OWNER'S NAME IIKE714JtJ a' e&10 '67x- PHONE
SITE LOCATION 4-L-/ _ ?i�z %,Ci �'�71z TO 11 2 -JV
MAILING ADDRESS
PERSON INTERVIEWED PCHD CaRplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INMAISEt , iG—`� �Z —T�t,� PHONE 511K 2 75 ° 60, 6
REGISTRATION #
Proposal _(include sketch locating all adjacent wells):
N=: 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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Inspector's Signature &
Proposal Disapproved
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roposal approved with the following conditions:
1. Procurement of any Town pernnit, 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
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 g of owner agree to the above conditions.
SIGNATURE TITLE DATE
OCP16: Wiibe (PO`D); Yellow (pn SI) • Pink (kq liaent.)
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME 0// PHONE
SITE I=TION �a� //C�i `,1 eiV 110
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE G v+ .v % TYPE FACILITY
PROPOSED INSTALLER V PHONE
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.
Proposal approved
Inspector's Signatu &e
with the
Proposal Disapproved
3 �
D e
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
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.
SIGNATURE TITLE DATE
OAFS: V&te (FAD): YeUcw (mn HI); Pink (Alum t)