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BOX 31
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PUTNAM COUNTY HEALTH DEPAR'IlENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE,DISPOSAL SYSTEM REPAIR
OWNER s NAME PHA
SITE LOCATION w 0 VC. 0
MAILING ADDRESS �2�(� ,CSC /A�� l`dg0 rV`r_N1t'4k VAC -L-CY 0S�s79
PERSON INTERVIEWED PCHD Complaint �
Name &Relationship (i.e, owner tenant, etc.)
DATE % TYPE FACILITY dS C-
PROPOSED iNsTALLER ,", 4,a cP7— PHONE FI-6 —P 5 7 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.
s
U vrH NP -c✓ (XP
SEc:4*cAct S
Proposal approved Proposal Disapproved
aac
roposal 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
drywalls 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.
SIGNATURE TITLE DATE L
I Off: Vhibe (PCHD); YeUcw (awn HT); Pink Qaiiamt)