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BOX 31
IN
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OWNER'S NAME
SITE IACATION
MAILING ADDRESS
V/
PirrNAM COUNTY HEALTH DEPAR'IIMENP
DIVISION OF ' ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEi M DISPOSAL SYSTEM REPAIR
-PH OW
PERSOIJ INTEEtVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER k Eon S 17 i• PHONE 4''-1 J- G z,?- J' o
REGISTRATION # C'� 3 3
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.
approved —
4� /, - 3
Date
proposal approved with the following conditions:
1. Procurement of any Tawn permit, if applicable.
2.,Su)mission 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 ccmponents tied to two fixed points (e.g.,house corners).
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, r reported agent of owner agree to the above conditions.
SIGN A TITLE it R DATE 1 d 2W3
PM: Hhite (PQI)); Yellc7w (fin HE); Pink (An2ja nt)
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