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BOX 10
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PUTNAM COUNTY HEALTH DEPARU4ENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES O
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR --
OWNER'S NAME PHONE ,,2 Ci
SITE LOCATION 71
MAILING ADDRESS A& %/L10 9
a
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE o[ 7f — .S -?
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 fran licensed professional engineer or
registered architect.
Proposal approved Proposal Disapproved
_ _.._
Inspector's-Signature &
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 ccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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
CPI6: White (PAD); Yellow (fin bit); Pink (AAaliamt)
DATE
PRIMP
Proposal approved Proposal Disapproved
_ _.._
Inspector's-Signature &
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 ccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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
CPI6: White (PAD); Yellow (fin bit); Pink (AAaliamt)
DATE