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BOX 11
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PUTNAM 0OUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL -FOR SEWAGE DISPOSAiL SYSTEM REPAIR
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS S 1:::j'4M
A7V3EL-
PERSON INTERVIEWED n��l. v Iy L < ►'1J _,�' PCHD Camplaint ##
Name & Relati ip (i.e, own , t, a .)
DATE TYPE FACILITY
PROPOSED INSTALLER 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 archi
I WAR
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� R
Proposal approved. 4 Proposal Disapproved
. - . r, s S ture Title
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 canpponents tied to two fixed'poi:nts (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 o'f 9wner agree to the above conditions.
SIGNATURE TITLE r�S ,�� DATE /
10
PIES: Hhite (PCHD); Yellaa (Tam BI); Pink (Applicant)