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BOX 10
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00951
CKWER'S NAME
SITE WCATION
QVDAZA
PHONE j ,?03- 7Y6 -fogy
TO
MAILING ADDRESS %; 41yerYn Dni2 AW /R-11-r
PERSON INTERVIEWED rn Z�~ I Owri4r PCHD Ccmplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 117 VIE TYPE FACILITY
PROPOSED INSTALLER -J q PHONE 9f Lj - jft: - J3 -7g
REGISTRATION # PL. - R
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.
Proposal approved --�
Inspector's Signature &
Proposal Disapproved
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
7de
(e.g.,house corners).
three precast 6' diam..x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
, as owner, or reported agent of owner agree to the above conditions.
IGNATURE TITLE J, L11,�cr. DATE//-/ 7 71
ES: Vbite (PAD); YeUcw (UNn BI); Pink (AFPUaait)
c s
D. INSPECTION Date ///;;�?/q�,',�Inspector
ONo evidence of failure
nEvidence of failure ❑Evidence of seasonal failure
i v
C\
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(Indicate North)
(1) Indicate location of SSTS
A. Size and type of septic tank gal
Metal OConcrete OPlastic
B. Type of absorption area
1. Fields, 'ft. 2. Pits 3. Gallies ft.
(2),Indicate_ setbacks,. front street, backyard, and side v_ and 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
OPWS ❑Shared well < In ivi well
Mrilled Mug OCasing above ground
COMMENTS: r% �► —`—z��
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVIDUAL ADDITION / REPAIR FORM
SECTION A. GENERAL INFORMATION
Nameof Project TM#
Year of Construction / � Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. Milly CIRO'lling OSteep'
slope G slope OFlat
2. (Mvidence of wetlands awareas sbject to flooding Modies of water
Mrainage ditches Mock outcrops
ES NO
3. Property lines evident?
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. Clevel Mentle slope Steeps ope
B. OWell drained Moderately well drained
Somewhat poorly drained OPoorly drained
C. Area available for SSTS. (Primary & Reserve)
Extremely limited 13Somewhat limited nAdequate ft x ft