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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
W11111 "I
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``?yOFFICIAL USE ONLY
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SITE LOCATION 3 k i lA b s-'o N ROAD FAIMOE o n/ TM# N b o 9)) - f- 31
OWNER'S HONE 1-03 14#4 s 7 S 3
MAILING ADDRESS U, SwoaxwinnnS 12o Haw EAia_ Er=g _0 G7 pb X12-
PERSON INTERVIEWED PCHD Complaint #
Name Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY 'S Co T S
PROPOSED INSTALLERS Z)La_ '�1 �Tz� PHONE
ADDRESS 6;'to -s g oa�-k� s 12n mga -3 VA r 2.f!9-;-4,oREGISTRATION#.
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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t�pbo . d ge ' owner agree -to the. conditions stated'on his'form. - -T.: ��...._..... _ _... _
SIGNAT[JIZE J TITLE (� GLJ 'yJ �,I r DATE
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 ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
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