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03932
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- 2251�0310,.
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
mm, s NAME 1�l (} -i'a G �i o PHONE ! `�
SITE I=TION � dl/o'�%L`i ��� y TO
MAILING ADDRESS
PERSON 619 can '` PCHD Complaint #
Nam & Relationship (i.e, owner,tenant,_etc.)
DATE —:;;-/z %e� TYPE FACILITY
PROPOSED INSTALLER
off PHONE S D -9 -- 671K �2
Pro (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.__//'
Proposal approved
Inspector's Signature &
Proposal Disapproved
77Dg e
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 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.
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SIGNATURE L �u�,z.. TITLE DATE
PISS: V&te (EM); Yellow (jai HI); Pink Ug l aint)