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OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH -- SERVICES---- - - - -__ -- -- --
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
TO Q S n ZY% 1 - q's
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER ,, 0 PHONE
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. ;� .�- % t k F� t
Proposal approved
's Signature &
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 showing:
a. Owner's name.
b. ite Street Name, Town and Tax Map number.
c. Location of installed camponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
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(e.g.,house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, repo4ted gent of owner agree to the above conditions. l
SIGNATURE TITLE DATE �!
CF16: V&te (PAD): Yellow Mkn HI); Pink (Pn2 ian* -)