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BOX 2
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00107
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OFFICIAL USE ONLY
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PERSON INTERVIEWED &,r 1:1 1'e, Zl� a e hi/ PCHD Complaint #
amlations ip (i.e., owner, tenant, etc.
DATE 7
PROPOSED INSTALLER
ADDRESS
TYPE FACILITY r e—s�.
REGISTRATION# J
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 reported agent of owner agree to the conditions stated on this form.
SIGNA r TITLE DATE��d,
P o a r ve Hlowin& 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.
Proposalapproved_
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Inspector's Signature & Title DA
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML