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OWNER'S NAME
SITE IDCATION
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MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTKENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES _
PROPOSAL FOR SEWAGE DISPOSAL SYST94 REPAIR ✓' ! ' 7S
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tt n PHONE 9/L 2-7f-90 Z V
S TO
PERSON INTERVIEWED ! PW Complaint #
Name &`Relationship (i.e, owner,tenant, etc.)
DATE J- I TYPE FACILITY e
PROPOSED INSTALLER �, es 6 :44- to PHONE
REGISTRATION # PG: e3j
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.
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7k) S`yslie4 Is Q gctd o - en_ OF VAJ74. //y
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Proposal approved
Inspector'lk�ignature &
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 eanponents tied to two fixed points (e.g.,house corners).
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 performed in accordance with the above proposal and conditions.
I, as owner, or rted ag t f er agr to the,above conditions.
SIGNATURE TITLE Q l..rw'- DATE
CPMS: WAte (PAD); Yellow (fin HE); Pink (AE Uamt)