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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIRy
(SITE LOCATION
OWNER'S NAME _
MAILING ADDRESS
PERSON INTERVIEV
DATE
PROPOSEDdSTALI
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OFFICIAL USE ONLY
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PHONE- 6 Vs
� s4i t ( , 1,.4 ,,1. 10s -37
.D PCHD Complaint #
Name Relationship i.e., owner, tenant, etc.
p y" TYPE FACILITY -
PjjHONE
k H 1 REGISTRATION# 3U
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be
i n 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.
97 r .r4 t: ti S , P �' I 1 �4 kvk i it1 %;� � u� / d3 O!3 604(—
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.I; as- owmer;, deporte"gnt-of•owner- agree -to the conditionQs stated- oh-this form..
SIGNAT TITLE % DATE Z-
E=osal aRp-roved 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.
Proposal approved
v
Inspector's., Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE