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00953
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00953
C6 ulavos PUTNAM OOUNTY HEALTH DEPARTMENr
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REP AIR
OWNER'S S NAME O- I EC4,4
SITE IDCATION -il a C a ,. l � A J Dr. P.Tn a TM# 1,V-1 1 l., S
PERSON INTERVIEWED PAID Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSID ; INSTALLER A ucA r $,� &� I.Nc-sevuj,r-c PHOO
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. R j C r w� j r / A
Il f n /a r P J P �I t i c � Cn v�l� � n P �, e cl �- . -,-uf d1
Inspector's Signature &
Proposal Disapproved
to
Toposal 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 canponents 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 ran �! or eent of er agree to the above conditions. ,
SIGI�ZURE ;t \ TITLE LATE
"I M : ?bite MD); Yel]aw (fin BI); Pink (FWlianit)
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