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03943
PUTNAM COUNTY HEALTH DEPARTMENT
ION OF ENVIRONMENTAL HEALTH SERVICES
.225- ,8/225
3.83- 3833/225 -8641
SAL FOR SEnTAGE DISPOSAL SYSTEM REPAIR
OWNER'S
SITE ID
MAILING
PERSON
�s
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY j'� % yk
PROPOSED INSTALLER A107- CZZ00 ��/�/ �L�_PHONE
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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Inspector's Signa ure & Ti
Proposal Disapproved
Proposal approved with the followincr conditions:
to
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, r reported agent o er gree to the above conditions.
SIGNATURE L TITLE DATE S 1 :Z I
PIES: mite (PCHD); YeUcw (?own HI); Pink (Applicsnt)