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01228
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
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TM#
PHONE 2 -7' f 7S—,S-
PERSON INTERVIEWED a c 1,4-o-- PCHD Complaint #,
Name & Kelationship i.e., owner, tenant, etc.
DA
TYPE FACILITY
PROPOSED IN�TALER `:r� PHONE
ADDRESS REGISTRATION# l/
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.
__ _,I,. as owner;
TITLE
%ATE
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 components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to 'be performed in accordance with the 'above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE