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BOX 13
01355
OWNER'S NAME
SITE WCATI
PUI'NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SENUM DISPOSAL SYSTEM REPAIR
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MAILING ADDRESS //X-, c v
PERSON WrMWIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
REGISTRATION # /11C W
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.
.RII Wi r . i.�:,
Pr a PP r ed Proposal Disapproved
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Inspector's Signa & n to
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 camponents 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.
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SIGNATURE TITLE
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