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BOX 10
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00921
OWNER'S NAME
SITE IDCATION
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMEWAL HEALTH SERVICES
PROPOSAL FOR SHKAGE DISPOSAL SYSTEM REPAIR
PHONE Z-7.e__ 0 7 %3
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MAILING ADDRESS ! - 4 iv 0, 1 y 4r A, Th, ,) A " %/ -
PERSON INTERVIEWED r% Pam Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITYUy
PROPOSED INSTALLER ,, ��, � , ��r� PHONEs� X73
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.
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Proposal approved Proposal Disapproved
Inspector's Sianature & Title Date
Proposal approved with the following conditions: It
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 camponents 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.
SIGNATURE TITLE DATE
PIN;: Waite (PG•D); YeUc w (on ED; Pink (An2la nt)
COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFO RMATION
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Name of Project --- (T)(V) TM#
Year of Construction i Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling ❑Steep Slopelent elope ❑Flat
2. ❑Evidence of wetland []Low area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
YES NO
3. Property lines evident? ❑
It
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. ❑Level Gentle Slope ❑Steep slope
B. ❑Well : ained ❑Moderately well drained
❑Somewhat poorley drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited ❑Somewhat limited ❑Adequate —ft x ft
D. INSPECTION Date Inspector
Mo evidence of failure ClEvidence of ailure ®Evidence of seasonal failure
-------------------------------------------------------
(Indicate North)
Y
C6
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(1) Indicate location of SSTS
A. Size and type of septic tank gallons
Me MConirete OPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallies. ','4�ft.
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(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
1jPWS []Shared well [Individual well
[Trilled Mug MCasing above ground
COMMENTS :