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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION
OWNER'S NAME _
MAILING ADDRESS
OFFICIAL USE ONLY %
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PHCONE 9qS-52,5;-7,3 1-7-
PERSON INTERVIEWED Q. C.e, 61 V2 SUS PCHD Complaint #
Name a ations ip i.e., er, enant, etc
DATE 3 n ^ <7) ( TYPE FACILITY
PROPOSED INSTALLER PHONE R qS -4)2--o
ADDRESS-3P RC-I l LL kWw 61 UgkQl , JS 16REGISTRATION# I '+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.
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v TITLE 0 DATE
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.
Proposalapproved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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