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04255
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF HEALTH SERVICES
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225 -0310
OPINER' S NAME , Z & V tif~M f *M W PHONE E28' —Of(C)9
SITE LOCATION eft -TWWO n( s f To to z . %
MAILING ADDRESS [ ., 0 , UX 1 l 0 S3 7
PERSON INTERVIEWED PCHD Complaint #
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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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Proposal approved �.
Inspector's Signatures. &
Proposal Disapproved
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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 canponents 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
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•, or reported agent of owner agree to the above conditions.
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