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BOX 25
02979
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02979
SITE LOCATION
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PUTNAM COUNTY HEALTH DEPARTMENT ( V*-
DIVISION OF ENVIRANMENrAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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PHONE 5- L8- 5 (
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MAILING ADMESS UW- t S^ %
PERSON INTERVYEWID PAID Caaplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE ��� �GT _ TYPE FACILITY
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PHONE
REGISTRATION # (S K
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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Proposal approved Proposal Disapproved
Inspector's Signature & Title
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applica ebl .
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 onrners).
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, reported agent of owner agree to the above conditions. c,
SIGNATURE TITLE 14t, g*r DATE
WW: Whine (PAID): Yellow (fin ED; Pink LNVUa nt)
PC -RP 97