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PUTNAM QO[]NTY HEALTH DEPARUMNr
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DIVISION OF ENVIRONNEWAL HEALTH SERVICES
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME PHONE %O �
SITE LOCATION oEdS% e�,W TO
MAILING ADDRESS aZrm -, J MY,
PERSON INTERVIEWED PCHD Catiplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE - TYPE FACILITY
PROPOSED INSTALLER �j. PHWt
REGISTRATION #
Pro (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. 1 19,9 -.0- n ,e-- , A S / r
Proposal approved
Inspector's Signature & Title
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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' diem. 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. 1 ,P-
SIGNATURE 6 TITLE DATE
IP16: V&te (PCID); Yellow (fin HI); Pink (Appl lint)
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PUTNAM COUNTY-DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project (T)(V) TM#
Year of Construction'G Size of Parcel
SECTION B.' TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolli ep Slope entle Slope ❑Flat
2. ❑Evidence of wetland []Low area subject to flooding ❑Bodies of water
❑Drainage ditches Clock outcrop
iES NO
3. Property lines evident? ❑
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4----Water courses exist on, or adjacent to parcel:
5. Existing individual wells within 200ft of the existing SSTS?
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. ❑Lev Gen pe []Steep slope
B. ❑Well drained ❑Moderately well drained
❑Somewhat poorley drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited ❑Somewhat limited ❑Adequate —ft x ft
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D. INSPECTION Date �S S e r
In re t•
DNo evidence of failure ClEvidence of failure e r�Evidence of seasonal failure
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(Indicate North)
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(. FOGS:
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(1) Indicate location of SSTS
A. Size and type of septic tank Lmlllloons
DiMetal ® Oplastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallies ft.
(2) Indicate setbacks, front street, backyard, and side yard dimensions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streamshvedands)
SECTION E. EXISTING WATER SUPPLY
OPWS OShared well [Individual well
11rilled MDug OCasing above ground
COM1 ENTS :
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