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HomeMy WebLinkAbout1152DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.56 -1 -79 BOX 11 mu I i 'L r - '1 ;. T ' IN 01152 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIROME14TAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR I Ur .7I � i � a FF III. 1 s• r PERSON INTERVIEWED PCHD Casplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY �F -5 PROPOSED INSTALLER 7 _�'r- J7Y� PROD 2170 -a n' 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. e-9— .. ^. n e /Ji tl�. _ ,•-' C'7tar aG-.. .. J �Zvr4&rZW4 .Irnr��i►T :� -►rte Proposal approved .-A• oposal Disapproved � a//, �_- Inspector's Signature & Title Proposal approved with the following conditions: 1. Procurement of any Tbwn permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Tbwn and Tax Map number. c. Location of installed components 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 �- TP16: % hite MV; Ye caw (3n ffi); Pink Unt i®nt) PC -RP 97 it JF l� i ,Q�p �rfLLau �LTll �„��2L�T�G�Du4<- 7-4wA, -r. �� 2-?9-�d69 aln D. INSPECTION Date pector MNo evidence of failure vidence of ure Evidence. of seasonal failure --------------- -------------------- --- - - - - -- dicateNorth) HOUSE P/� (1) Indicate location of SSTS A. Size and type of septic tank . , Metal []Concrete B. Type of absorption area 1. Fields $. 2. Pits gallons . Galhes $. " 'cate setbacks, Mont street, backyard,.and side yard dimensions. rhowlocation of well lo cation of driveway oe —,0'0 ote physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING WATER SUPPLY MPWS, ft well DDrilled ®Dug 13 Casing above ground COMMENTS: eV M111 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL ADDITION /REPAIR FORM. SECTION A. GENERAL INFORMATION OL Name of Project 6-04501:- 4 �3 0 f TM4 / `� -,(T)(V) Year of Construction Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. ®Hilly Rolling ®Steep slope --,en e lope ®Flat 2. ®Evidence of wetlands OLow areas subject to flooding ®Bodies of water ®Drainage ditches' kock outcrops 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. ®Level ente slope LJSteep slope B. O Well drained ,..Zko&ately well drained ®Somewhat poorly drained OPoorly drained C. Area available for SSTS. (Primary. & Reserve) O Adquate ft x ft ®Extremely limited ®Somewhat limited