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BOX 28
03500
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES, _ v
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<:225 -0310 _.
PROPOSAL FOR SEMM DISPOSAL SYSTEM REPAIR
OWNER'S NAME !L ,S� ���} r M end PHONE
SITE LOCATION __4J 6, RoCNI ALC Oomg 'tt(WrAwg,jTM#
MAILING ADDRESS P y't CY A M V P( L L F
PERSON INTERVIEWED PCFID Camplaint #
Name &Relationship (i.e, owner tenant, etc.)
DATE h fit' TYPE FACILITY
PROPOSED INSTAL1M +fo w &-o G&*6 jCfi T PHONE
��•T Cs G.i c � 13�
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.
•.�ti_
's'Signature & Title
Proposal Disapproved
r000sal amroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
1[2,j�
Date
(e.g. house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner,: r reported agent of owner agree to the above conditions.
SIGNATURE TITLE A6,Fev- — DATE V
PM: V&te MV; YeUcw (fin ED; Pink LAppl.ia mt.)
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rN-& F P f _ ..
_ S'A.Mr. A."
Lor�7,ttn"
•.�ti_
's'Signature & Title
Proposal Disapproved
r000sal amroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
1[2,j�
Date
(e.g. house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner,: r reported agent of owner agree to the above conditions.
SIGNATURE TITLE A6,Fev- — DATE V
PM: V&te MV; YeUcw (fin ED; Pink LAppl.ia mt.)