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BOX 5
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OWNER'S NAM.
SITE LOCATION
MAILING ADDRESS
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PUTNAM COUNTY HEALTH DEPARTMENT'.
DIVISION OF ENVIRM402 TAL HEALTH SERVICES
PROPOSAL FOR SHQGE DISPOSAL SYSTEi;REPAIR 2 2 �y
PHONE
TO
PCHD CaVlaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PROPOSED INSTAIUM, 92 AAJ V-0-h " , eN t' %" PHONE '7
REGISTRATION #
Pro (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.
0
/ G°, a
Proposal approved Proposal Disapproved
s Signature & Title
-I
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
....2. Submission ofas built repair sketch in duplicate showing:
a.'OwnerIs name.
b..Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points (e.g.,house corner's).
d. System,descripton (e.g.',.1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells,surraunded 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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