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BOX 18
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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SITE LOCATION
OWNER'S NAME %A
MAILING ADDRESS
OFFICIAL USE ONLY
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER J e E-Ple - 6? A-P e- / �q PHONE I co 3
ADDRESS Y3 - iLiot-i_t1cf htew F*tor -e kd et, REGISTRATION# rd, !
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.
as Owner,.or-reported gentof owner agree to the conditions stated on this form. _ _..
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SIGNATURE TITLE DATE
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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 wi Tbpe oposal and conditions.
Proposal approved of
Inspector's Signature & Title I
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML /1 IV �GL t`.�dt'�/�
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