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BOX 11
01092
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Ar
01092
OWNER'S NAME
SITE LOCATION
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PUTNAM COUNTY HEALTH DEPARMENP
- DIVISION Of-.ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
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Name & Iglationsnip (i.e, owner,ta
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REGISTRATION # P,4-
20
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PCHD Camplaint #
ant, etc.)
TYPE FACILITY h6lne.
PHA 91/- fSX - 3S'73
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 fram licensed professional engineer or
re ,gis` }eqd architect.
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Inspector's Signature & 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 canponents tied to two fixed points (e.g.,house.00rners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number. .- . ........... _..
3. System repair to be perfonned in accordance with the above proposal and conditions.
I,,as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
MM: White (PQI)); Yellow (Tam HE); Pink (,A%licent)
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•••-. •• • _• •••-. •• • a•
Inspector's Signature & 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 canponents tied to two fixed points (e.g.,house.00rners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number. .- . ........... _..
3. System repair to be perfonned in accordance with the above proposal and conditions.
I,,as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
MM: White (PQI)); Yellow (Tam HE); Pink (,A%licent)