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BOX 10
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00920
OlAM' S NAME
SITE IDMTION
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PERSON iNTEtVIE4MM PM Casplaint i
Name & Relationship Me, owner,tenan "t,'etc.)
DATE TYPE FACILITY
P�POSED INSTALLER PHONE
REGISTRATION # �r � v
Proposal (include sketch locating all adjacent wells): ! y�! d S
NOTE: Repair must be in same location and of same type as original sewage disposal syst ®.
Different location may require submittal of proposal fran licensed professional engineer or
registered architect. /2 11 .1 -4
M
M.
Proposal approved Proposal Disapproved
Inspector's Signature & Title Date
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
214 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 oamponents tied to two fixed points (e.g. 'house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' disco. x 6' deep
dxywells 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. r/
SIGN MRE � _ 3 ; TITLE DATE / "' /91 _
IMS: White (POD); YeUcw (con HE); Pink ftp csnt)
PC -RP 97
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67-01
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TO lER 17 ve9T,
D. INSPECTION Date' , Inspector -
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No evidence of failure ence of failure ❑Evidence of seasonal failure
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(Indicate North)
HOUSE
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
111%9etal Concrete ` ❑Plastic
B. Type�fr s'
1.fFields ft. 2. Pits 3. Gallies
(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, streams /wetlands)
SECTION E. EXISTING WATER SUPPLY
13PWS D Shared well
COZ B ENTS :
REPAIRS ONLY: Status:
❑Individual well
13Drilled ®Dug ❑Casing above ground
As Built Inspection Required: As Built Submitted:
As Built Inspection Done: Inspector:
PUTNAM COUNTY DEPARTMENT OF HEALTH - - "
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL RNIA��
Name of Project (T)(V TM#
Year of Construction Size of P
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ®Rolling / Steep Slope Mentle Slope . ®Flat
1
2. ®Evidence of wetland Clow area subject to flooding ®Bodies of water
®Drainage ditches Clock outcrop
3. Property lines evident?
4. Water courses exist on, or adjacent to parcel:
YES NO
5. Existing individual wells within 200ft of the existing SSTS? ®^
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing S TS area.
A. []Level` Gentle S1eSteep slope
B. ®Well drained ®Moderately well drained
[]Somewhat poorly drained ®Poorly drained
C. Area available for SSTS. (Primary & Reserve)
®Extremely limited ®Somewhat limited ®Adequate ft x ft