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02026
PUI'NAM COUNTY HEALTH DEPARTMENT 9
DIVISION OF ENVIRONMENTAL HEALTH SERVICES '
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME 2 - PHONE
SITE LOCATION %f�Gf.E= :i.�,� Ak1 T"1
MAILING ADDRESS
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE r,J TYPE FACILITY PROPOSED INSTALISEt/�;'' _ �a;L_ PHONE
REGISTRATION #
Prcposal-(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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Proposal approved roved
s Signature & Title
// / ; lx� to
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, o� reported agent of owner agree to the above conditions.
SIGNATURE -Z, TITLE DATE i
PUS: W dte (PCfD); YeUcw (fin EU; Pink LkIliau t)
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S-06
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-72-76
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