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BOX 14
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01549
OWNER'S NAME L' ,
SITE IDMION % >
MAILING ADDRESS etaf"
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
HATE TYPE FACILITY -
PROPOSED INSTALLER PHONE
REGISTRATION # 0Y�t-
1 (include sketch locating all adjacent wells):
NM: 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 Disapproved
toposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Subuission 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 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 a ent of owner agree to the above conditions.
SIGNATURE `' t^ TITLE�GL� DATE
PUS: *dbL- MM; YeUcw ('in ffi); Pink Lkpli®nt)
PC -RP 91
PUTNAM COUNT' DEPARTMENT OF HEALTH - -
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project (T)(V)
/51
Year of Construction Size of Parcel
TM#
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling ❑Steep Slope Lntt6'Slope ❑Flat
2. ❑Evidence of wetland [Tow area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
YES NO
3. Property lines evident?
4. Water courses exist on, or adjacent to parcel: ® U
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 drained Moderately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited C3 Somewhat limited ❑Adequate ft x ft
t
PUTNAM COUNT' DEPARTMENT OF HEALTH - -
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project (T)(V)
/51
Year of Construction Size of Parcel
TM#
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling ❑Steep Slope Lntt6'Slope ❑Flat
2. ❑Evidence of wetland [Tow area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
YES NO
3. Property lines evident?
4. Water courses exist on, or adjacent to parcel: ® U
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 drained Moderately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited C3 Somewhat limited ❑Adequate ft x ft
D. ,INSPECTION Date inspector
No evidence of failure OEvi.denp of failure ®Evidence of seasonal failure
t I .
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(Indicate North)
H
(1) Indicate location of SSTS 1Ci
A. Size and type of septic tank_ gallons
Metal Concrete OPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallie� ' ft.
(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
CIPWS M Shared well (Individual well
f ®Drilled []Du- ®Casing above ground
CONT BIENTS :
REPAIRS ONLY:
As Built Inspection Required
Status:
As Built Submitted:
As Built Inspection Done: Inspector:
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