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BOX 12
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01315
PUTNAM COUNTY HEALTH DEPARTMENT
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR "0
OWNER'S NAME S �� -� PHONE o276 - d07-?V'
SITE LOCATION IIA—Mi lty-4 Az- &Zt2 Amu &AXZ'r' TO n`l J • 71 • a - �J
MAILING ADDRESS &2C5g�,A.
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
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.
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Proposal approved Proposal Disapproved
Inspector's Signature & Title DatK
with the follawinQ conditions:
t. Procurement or any •rown permit, it applicaale.
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' 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 reported agent of owner agree to the above conditions.
SIGNATURE DATE S-,
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Proposal xapproved�h� oposal D sappy 5 4 y�� r
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Proposal; approved with the following - :conditions: r� "., F K ,
'1. Procdranent of zany TOwn permit, f 'apple ea B r ��s� "w }� � SUFI x` � .0 il + r w
2.,' Suianission of as `built repair sketch in duplicate showing: �� .�'�� `' 4 ` s , r
sr , a ,AQwni is ;name - - °:ply ., ." d r X31, , 2 h4;l., , y ' ��� 3 r ^''
y�, b.t Site Street SName, ; down and Tax Map number. ' t s�. �t� '� a
> ?�c Location,. Hof `installed oanponents tied to two fixed pouits (e:g. haise'oorners): r, , j;�- I-
4 2 r d.� Systan . clescrip . , M.:( e.g. =; 1250 gala concrete septic tank, three prec�st� t6 ! Adiam.';x', "*!, ' d� ,
'M� bdryw�ells�: "surrounded„ by .one foot +gravel) .
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+' `'e 'Installer' d "` -7- ne: ahcl number. x
?�3'System repair: ,to be perfornied in `accordance with, the above proposal and:oonditions: , ' d
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yI as a�wmer;,� nor reported agent of 'oti�mer agree t, the "above oonditions.�, r „ °§ , , a}
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