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BOX 12
01312
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01312
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES'
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
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OWNER'S NAME I / J�/ (� PHONE
SITE LOCATION fib$
MAILING ADDRESS �- k °c— S 120 Y
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.) .
DATE TYPE FACILITY
PROPOSED INSTALLER Jfb --5
• i i t
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.
- \1K
o l D or W W
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Proposal approved Proposal Disapproved
s signature &
with the following. conditions:
Des
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 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 perfomied in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE 4a TITLE DATE
OM: V&te (PAD); Yellow (kai HI); Pink Uqi iamt)