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01819
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
&016 Q!M4� OFFICIAL USE ONLY
SITE LOCATION F1 I )per - I 01C4
OWNER'S NAME PHONE 516 ^ 7W IV - a � L�
MAILING ADDRESS
PERSON INTERVIEWED I PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc.
DATE �e TYPE FACILITY
PROPOSED INSTALLER,8rA or&/,: S �' �J `
�-1- �- � "'� „�•�_ PHONE �yS
ADDRESS0? tT- t� hA SLtil aj W 3 Y, A n �,- K REGISTRATION# f l ffTO-
Proposal (include sketch locating all adjacent wells): I`�'���i
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.
Pie u.se eel/ 2- 7 0 °C13 -0- X 2 61
I, as:owner, or reported agen f
7/
er gree to the conditions - stated o this form. - -
SIGNA DATE Z
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 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
Z I t z
DATE
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