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00677
PUI'NAM COUNTY HEALTH DEPARTMENT k1)
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER' S NAME
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PHONE
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SITE LOCATION
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MAILING ADDRESS A /�O
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY= ���E,y�7�g�
PROPOSED INSTALLER PHONE 279 • G66
REGISTRATION # mil/
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
Inspector's Signature & Title
Proposal Disapproved
romsal aunroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywPlls surrounded by one foot + gravel).
e. Installer's name and number.
z$ 9s
Datd
(e.g. house corners).
three precast 6' diam. x 6' deep
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 Mt. MM 7 -D
CKES: W-dte (R'1D); Yellow (Ttkin HI); Pink (Applimnt)
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