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00174
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION Ll b "A vi A
OWNER'S NAME �� 4, i` `1
MAILING ADDRESS A i,011 RU J ,J
OFFICIAL USE ONLY
TM# ` 10 - / ` ",),
PHONE, "°i
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
DATE
PROPOSED INSTALLER
TYPE FACILITY
ADDRESS R4q Z0 4�t�; i a' : f 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, r: ep rte gent of owner agree to the conditions stated on this form.
SIGNATURE TITLE - ,,Z : 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 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.
Proposalapproved
Inspector's Signature & Title A
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML