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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES - - -- - --
il T R, ,G `q PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER' S NAME Z /'-'7 Q4 PHONE
SITE LOCATION A aa,
MAILING ADDRESS
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER �/✓ °S 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 from licensed professional engineer or
registered architect.
Proposal approved
Proposal Disapproved
Proposal approved with the following conditions:
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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 nanp and number.
3. System repair to performed in accordance with the above proposal and conditions.
I, as owner,
SIGNATURE
MIS: V& be (PAD); Yellow (Tam H0; Pink (Applicant)
the above conditions.
TITLE DATE