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BOX 7
00543
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OWNER'S NAME
SITE LOCATIOT
PUI'NAM COUNTY 'HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
f j "10- 97
PHONE �QS^ 39&-S—
TO
MAILING ADDRESS C iO cyn -- C- 0- cr"CL- j�,W, a
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, cwner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER tax" S 0: ti 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 frcm.licensed professional engineer or
registered architect.
yo
Proposal approved _
Inspector's Signature' &
Proposal Disapproved
Date
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' &am. x 6' deep
dzywells 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 agenntt� of owner agree to the above
r conditions.
SIGNATURE T1IIA,�I 1'0w :roa/ A TE 110P, 91 Mp G
PM: Wiibe (PC D); YeUcw (fin ED; Pink (AFpliaaat)