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01060
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01060
. PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
A. - -_.
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR ! A5va
OFFICIAL USE ONLY
SITE LOCATION
OWNER'S NAME
.MAILING ADDRESS
,-.2
PERSON INTERVIEWED I`%1'F & PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc. '
DATE
PROPOSED INSTALLER
,ADDRESS a d V,,b_ C� Q, Ae >so
TYPE FACILITY ',� �) P t)
PHONE ' a 7 C/- ?.SS I
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.
I 1 l b J !-F ^ rl U /d� �►r1 C�/I�'Y M M ✓ !j -/
" I;'ag,ow er, or rted a nt of owner-agree to the conditions stated on this form. -
SIGNATURE TITLE (') %` P V DATE L O C'
Proposal aAnroved 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 (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
, 3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approve
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
Z _3102-r-1
DA
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_________ __ _.__..___. __ _________ .___._. _._ - ----------
I__ "P. 1..__.... 11- 1 11
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'PUTNAM -COUNTY HEALTH DEPAROMNT f
DIVISION OF ENVIRONMENM HEALTH SERVICES
PROPOSAL F OR SE14AGE DISPOSAL SYSTEM . REPAIR 7 0-os
pH= 7
OW NER' S, NAME All e le, IA,9611L
SITE LOCATION &tvrenev 4�ki'IC 20 2
mAIWS /�y
UM ADDRESS -per
PERSON INTERVIEiaID G C d- &1,4 "Al ire M_)W� PCHD::-Catip.'a,int #
'Name & Relationship li.e, owner,,tenant, etc.)
ATE TYPE FACILITY
PROPOSED INS*TAUUM bc SC_ PHcNE
REGISTRATION #
ftioposa (include sketch all adjacent wells):
NOTE: Repai , r,must be in same location and of same type as original sewage disposal system.
Different -location may require -suhnittal of proposal fram,licensed professional engineer or
registered arcfi,itect-.'.
- rsys'/i -rJ f,5,:L,5 IAl's'xyy e ;5;°d7 15, 04D Ir /e4fzi-
M__.MW
the
19 /42r,�
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1. ..Procurement of ,any Town t, if applicable.
2. submissionz�.d as s bu. . built repair sk6tdh in4uplicate showing";
a. Owner I s name.
b. Site Streii t.Nweo, Town and Tax Map number.
c. location of iiigtalled carponents tied to two fixed points (e.g. house corners).
d. System descriptiori,,(e.g., 1250 gal. concrete septic tank, .three precast 61 dim. x 61 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.
as owner, or reported,,agent.of owner'..#gFep.to.the,above-conditions.'
SIGNATURE TITLE DAM P// (k
IM: Vbite MM YeUcw (fin EI); Pink (APPIiamt)
`C-RP 97
gr
7.
D. ENi TSPECTION Date` Inspector r ® °%1 fh:
E]e \To evidence of failur �idence of.failur' .Evidence of seasonal failure
- -- - - - -- - - - - -- - -- _.
r -�:,� - - - - - - , - - - - - (Indicate North) ., .
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_ Fous-
y �o
- w
71 - w - w - - - - - - - - - - - - - - - - - - - - - - w
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
-'
Via.
®Metal O'Concrete : Oplastic
B. Type of absorptiob'&ea
1. Fields "ft. 2. Pits 3. Gallies ft. - -
(2)1ndicate'setbacks;11ronf street, backyard, and side yard dimensions
(3) Show location of well'
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streamshvetlands)
SECTION E. EXISTING WATER SUPPLY
0PWS 05hared well Individual well
ODrilled ® ground
COMMENTS:
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