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04152
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04152
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SITE LOCATION
I IAdAI �T�Ti ;iP��l
PUTNAM COUNTY HEALTH DEPARTMENT ���y� ,Ud� �c•�Y
DIVISION OF ENVIF40NMML HEALTH SERVICES
PROPOSAL FOR SEti+Il M DISPOSAL SYSTEM REPAIR
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PERSON IITERVIEWD PM Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
GATE -+.. e3 TYPE FACILITY
PROPOSED INSTALLER �y3?t,� �.9-� � PHCNE 5- Sy S.
REGISTRATION # -�
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal systea.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
a ave, & & -
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Proposal approved I Proposal Disapproved
Insvector's Signature & Title
Pr000sal aooroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
� 3
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be perfonred in accordance with the above proposal and conditions.
I, as owner, o reported agent of owner agree to the above conditions.
SIGNATURE / TITLE�,Q�
3PW: %kite MD); Yellow 03n BI); Pink (AFpUcmit)
PC -RP 97