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BOX 6
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00300
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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PERSON INTERVIEWED l/ /CG c/ --0,
& Relation
DATE����
PCHD Complaint
(i.e, owner, tenant, etc.) .�'%�'% e.• -,ga
TYPE FACILITY _
PROPOSED INSTALLER �/ �/� /y-4 PHONE CLZ4y ate{
REGISTRATION # d / -3Gx 30
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 approved � Proposal Disapproved
's Sianature &
with the
inq conditions:
Ily
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.
SIGNATURE L44 TITLE DATE
I PM: White (PQHD); Yellow (T,n BI); Pink Qg2iant)
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