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00617
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SITE LOCATION
OWNER'S NAM]
MAILING ADDR
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
k 6 �/-o I
PERSON INTERVIEWED PCHD Complaint #
ame Relationship i.e., owner, tenant, etc. t.
DATE G/�f % //�/ TYPE FACILITY r
PROPOSED INSTALLER 5d PHONE
ADDRESS 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.
I, as owner, or reported agent of owner a ee to the conditions stated on this form.
SIGNATURE TITLE DATE
sh 9
R
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 comers).
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 A
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
PUTNAM OOUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR 1 7
1 A w
OWNER'S NAME ` ti' 4 o -w- �'r b ' PHONE
SITE LOCATION /�% ,�'1�.� flu s �ec-s� �z 7M#
I+ nING ADDRESS C
PER SON. ` INTERVIEWED PCHD Complaint #
pame & Relationship (i.e, owner,tenant, etc.)
DATE-. FACILITY,
PROPOSED INST �. f�_ ��c�,P_ d- PHONE Z.
Pr222sal (include sketch locating all adjacent wells):
NOTES Repair must. be in same location and of same type as original sewage disposal system.
Different location may require suh mittal of proposal from licensed professional engineer or
Proposal approved __,,`e— Proposal Disapproved
]Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showings.
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. Syst.etn 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 y,�,� ,.`T�, /�� TITLE Q_ DATE_
3W4'Ss V to MCLO; YeUcw (fin ED; Pink (Anlacsnt)
MWOWOUR , r
Proposal approved __,,`e— Proposal Disapproved
]Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showings.
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. Syst.etn 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 y,�,� ,.`T�, /�� TITLE Q_ DATE_
3W4'Ss V to MCLO; YeUcw (fin ED; Pink (Anlacsnt)
SITE
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
P1�OPOSED INSTALLER, 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 fran licensed professional engineer or
registered architect.
0
SS '0�°`� �` w�rr m Ioe replaCed
Diri .../_ ) _
Proposal approved ':�k— Proposal Disapproved
with the following conditions:
1. Procurement of any Town permit, it applicanle.
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 canponents 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 TITLE DATE O
nFUS: %tine (PaD); Ye]1aw (Tam HE); Pink LJ#iaint)
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