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BOX 30
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PUTNAM COUNTY HEALTH DEPARTMENT
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OFFICIAL USE ONLY
SITE LOCATION S � � k , i hol l� P�. Ly. # 7 a o -
OWNER'S NAME ti r}z _ PHONE 52�W A /'Z—
MAILING ADDRESS 757i -kM-e_ y1 S
PERSON INTERVIEWED - W. PCHD Complaint # ()/l t
ame & Relationslup ,owner tenant, etc.
DATE // —Z3 — a y TYPE FACILITY
PROPOSED INSTALLER , c_ _� PHONE Z2--7 — YS 0, 5-
ADDRESS X5 e,, c hle, 74 REGISTRATION# / % 2-
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.
-I; as owner, or reported agent of owner agree to the conditioris'stafeea on this form.`
SIGNATURE TITLE /1f�/'��r/41 -+ C7— DATE � / 20
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 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.
Proposal approved
pector's Signature & Title D
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML