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04205
PUTNAM COUNY'S[ HEALTH DEPARTMENT Howard Gr%ptt
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
X96 0600 9�08�. 79
VOW
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
0`*M'S NAME 1 Ac d-
SITE IACATION ` jnf9 :rd
MAILING ADDRESS L -cam
PHONE 2 t-- 7e -L6
. W �<13 E!?16 t - . &6
PERSON INTERVIEWED PCHD Ca%aaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE " TYPE FACILITY
PROPOSED INSTALLER u" G'�7A'b` A � %,1 ;-60 PHA
REGISTRATION #�'�
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original swage disposal system.
Different location may require submittal of proposal fran licensed professional engineer or
registered architect.
Proposal a ov Proposal Disapproved
Ins is Signature & Title Dktia
'_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' 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.
[, as owner, or reported agent of owner agree to the above conditions.
30IGNATURE Cam' 1. TITLE 6-6f y- ` DATE le, '
W: Vbite (PAD); Yellaa (Tam HO; Pink (Applicant)