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BOX 18
01941
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01941
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
33- o
SITE LOCATION . aIL{ dew At TM# 3 4
OWNER'S NAME PHONE
MAILING ADDRESS
PERSON INTERVIEWED 6 w +^ R r PCHD Complaint #
_ I I Name & Relationship (i.e., owner, tenant, etc.
DATE
PROPOSED INSTALLER ".l6 rv\ Lpn
ADDRESS , C �b
TYPE FACILITY Spni-,�c
PHONEd'{S d 79 — -7 S S /
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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" - J;"as*owrier, or r ort a nt o er agree to the conditions- stated on this form.
SIGNATURE TITLE (j 1= ra .0 A— DATE
-Proosal 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
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