HomeMy WebLinkAbout1017DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.47 -1 -65
BOX 10
01017
..
,
Le
Ilk ..or
0
F
or
6
r
F
,
r
,
01017
y2
OWNER'S NAME.
SITE LOCATION
MAIL
DATE
PUTNAM COUN'T'Y HEALTH DEPARTMENT r
-- , -. _ DIVISION..OF_ HEALTH_ SERVICES...__....
J X-14r 00 X79 4
•ter ��,
PHONE
TO
MAILING ADDRESS --
INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
4 --S'99 TYPE FACILITY &Ae,
PROPOSED INSTALLER �mts- - (may mr, o
PHONE 919- XTJ - 3S-73
REGISTRATION # _PC. J'3/
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.
Proposal approved,
s Signature & Title
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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 lelo TITLE .s /�z�. DATE
IM: Write (POED); YeUlc�w (Tam ED; Pink (AppUamt)
0�
=min
-e
i
fe.
''------------- � '------
D. INSPEMON
|
----____�-
spector�_��_____
ONo '
p`d*nrp�ff�Mnrp �� � �f f�uc�
e
�
| 1
�~-`- �
| ~~~-~~~ ~~~-~.----~~~~-~~~---~- -~ � -- ---�~ - -------------
^
x�+°^°ate N°^=v
y
. . .
.
°
'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
.
(1) Indicate location of SSTS
A. Size and type of septic gallons ---------
OCon'crete
�__r»u��u O^^""°°
B. Type of area' '
1. Fields ft 2�m 3, G�M�
, __---_- -
- -----/J\ Indicate setbacks, frOtt8tteeC backyard, and side yard dimensions-
(3)
��n`r of well
/
~�~-~'---~-~^~--
&��
vv~^-'~ ^~~-~~~~^ of
driveway -
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
SECTION E. EXISTING WATER SUPPLY
OPWS
IjShared well M6M'. well ---~�`
Mrilled ODug �
�
| 0 Casing above ground
, ,�-}
COuu»u�mTS. ,''� /~/
PUTNAM COUNTY DEPARTMENT OF HEALTH
DI'6TJ[SION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INI; UA.L ADDITION/ / REPAIR FORM
SECTION A. GENERAL INFORMATION
. J 1 ,
Name of Project
• � � lay Qr
Year of Construction `Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
®Steep slope lope Flat
Clow areas subject to flooding Clodies of water
1. Hilly Rolling
2. ClEvidence of wetlands
ODrainage ditches Rock outcrops
1 YES 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 SENYAGE TREATMENT SYSTEM (SSTS)
1. Physical character of existing SSTS area.
c
A. []Level Mentleslope ?S't'e'epslope
B. 0Well drained Moderatefy well drained
13 Somewhat poorly drained OPoorly drained
C. a 'e Tor (Primary. & Reserve)
xtremely limite - omewhat limited
Adequate ft x ft