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01939
mom 01101
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
"S,-P"O"-S--A-*L"SYS"T, E*M- '-
OFFICIAL USE ONLY
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SITE LOCATION (A It c n lloS noc, v-m7
OWNER'S NAME AJ E'l 1;-!.% PHONE -TtAck
MAILING ADDRESS--�. a3et l y, L'Irrs< 'Q &L.5
PERSON INTERVIEWED "AaQ-0%Lf 0AXAM11D Complaint#
I I Name & Relanoni mp ti.e., owner, tenant etc.)
DATE TYPE FACILITY-�c &v c-
PROPOSED INSTALL HONE 1® 741 C -7
ADDRESS 141- 114100� I?Cf 1 �14V�PR�MEGISTRATION# L L�f—X
Prpl2osal (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. I
as owner, or reported-agent-of owner agree-to the-conditions stated on this form.
SIGNATURE TITLE_ to %&I C DATE , -- e-4-W, . �t-- -
Proposal g]=ved i Ilowin onditions:
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'diarn. X 6' deep
e. Installers' name and number.
performed in accordance with the above proposal and conditions.
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC-RP 99ML
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DATE
i acknowledge receipt of this report: SIGNATURE:
/96
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Title;
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JOSEPH MIA
43 WOOD'.
NEW FAIRfIELD,CT.06812
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