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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION LA g 'Z->e -tZ A 2D .1_;, VfA6 Y2 - r;
OWNER'S NAME S �.r 1.v9 f oft sir PHONE 5 ,2 ? V 91 Z
MAILING ADDRESS
PERSON INTERVIEWED ! PCHD Complaint #
ame a ations i i.e . owne , tenant, etc.
DATE _ / -7 - e-D '3 TYPE FACILITY d S
PROPOSED INSTALLER A � 9,cx. ` x L, 1 w- ! PHONE
ADDRESS %1.,w,-w,e/l„T % k 4i ,403 REGISTRATION# 1 -Z-
Proposal (include sketch locating all adjacent wells): i
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.
'00ye Tom» /- f 6:4 //6, o, V i:- ..1w S ✓•,-c, c._
I, as owner, or reported agent of owner agree to the conditions stated on this form. 7 l
SIGNATURE 2 :j2 DATE J ' % �-D 3
Proposal approved_with the rdlowine 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.
Proposalapproved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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