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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
C1*M1S NAME �` D WA1` - L P-r Tc id
SITE LOCATION oL 15 G tf At o P js L4,1 (,ow t?-1
MAILING ADDRESS 2 19 CA-P-ob f �J S f�o i 6,,J kJ
PHONE
l` t0- 07 4'
PZtSCN R TERVIEWM I PM Caaplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER 0 wfig r C (-5-Ps t-'AJ ) - -
PHONE
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.
110a 541 �*rlL
0 _
Proposal approved . Proposal Disapproved
Inspector's Signature & Title
�oposal'approved with the following conditions:
I. 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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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, or reported agent of owner agree to the above conditions.
QGN ATURE . % � i�.oAd /� 5 _ _ '�� T 'LE
CKE4: %hibe (PCH)): Yellow Mahn ffi); `Pink
PC -RP 97
PATE
FJTNAM COUNTY AFALTH _ q7
DMSIatT OF F�1fTI . AL NTH `SFIaS
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PROPOSAL EM DISPOSAL, SXSTEM REePAIR
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PEd iT%II� Complaint #
game rx Relationship Ude; owneratenant, etc °)
° MLLE ... C� W r/�..f . C Lads- L�jhj) Pii � - 3
REGISTAATI,ON #
Pr6posal (include 'sketc o loratinq all ad• cent wells).-
*IOTEo Rep ir must be in same ltion.,.aid of same .type .as original sewage' disposal system.-
piffereai loati,661may iequire sutmitpl of proposal -;from licensed professional engineer or
regis i r-ed itect°
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Paosal appri Proposal Disapproved
i
" InS�1eC$Or ° Slgnatilre Title ,, . ter
a roaied with the following conditions or
1 °',.Promirepent�of any Town permit,, if applicable.'
a° Submis6i6n`- `of- -as built repair sketch in duplicate .showing: �
a° caner :�s `name°
b lsatcI'Street Namej' Town and' Nap - humbegm .�'
00 'Iaion of ,'installed oaanp�ts tied two, fib points. (e.g. ,house oorners) °/
descri
Sys 4t ': (e�g:'a ° 2 0 .gal,, concrete septkq,aankO, three precast 6' diam° x 61 deep
dryviells' . surrounded by � one foot +gravel) °
d,'., Installer sname: and number,,
3 o System repair, to be • perfon ed in - ,kc�or. . ce with the above. proposal and conditions
Y ®aa owner,, o$ reported agent of, owner agree to the :oonditionstT
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Pr -RP 97
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