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41
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
UP1D►SAL FO 2SEWXU DISPOSAL SYSTEM Y2EPAIR f
SITE LOCATION < -,
OWNER'S NAME
MAILING ADDRESS —72-20 1 . -e�
OFFICM USE ONLY
!2
77 --0 -2---
TM# S `z e
PHONE
PERSON INTERVIEWED 12& PCHD Complaint #
ame a ations i.e., owner, tenant, etc.
DATE 0�0116/a —V—. TYPE FACILITY
PROPOSED INSTALLER PHONE
ADDRESS
REGISTRATION#
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.
..I, as..owner,, or_rep rted age9t of :owner agree to. the conditions stated on this
SIGNA TITLE 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 corners).
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
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
/�/®e--
DATE