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BOX 15
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01675
PUTNAM COUNTY HEALTH DEPARTMENT
* * DIVISION OF ENVIRONMENM HEALTH SERVICES
fit;' W Y O4$ PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME Z ��lit 7"c1 PHONE 2- Z 7 S� _
SITE LOCATION �j '� 1'Cc.l'yv► mQ r TO
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE TYPE FACILITY
REGISTRATION # 13 1 W /
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.
ffroposal app Proposal Disapproved
G
's Sianature &
rocosal annroved with the followincx 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 cmiponents 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.
1
(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.
I, as owner, or repprted agent of owner agree to the above conditions.
SIGNATURE TITLE d DATE _7'`'" 11 r
-------- e9/�" 7— 7
CP16: WAbe (PLED); YeUjow (fin ED; Pink Vg2icant)
PUTNAM COUNT' DEPARTMENT OF HEALTH . s
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORIMATION
Name of Project (T)(� TIVI#
t
C' .
Year of Construction : �� Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1.. ❑Hilly ❑Rolling ❑Steep Slope ❑Gentle Slope ❑Flat
2. ❑Evidence of wetland ❑Low area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
3. Property lines evident?
YES NO
❑ ❑
course °sexist on, or adjacent to parcel:_... _ .��:a_: ��.-- -w -`'- .°❑ _ - ��:__. - - -:. �_.--- - - - -•-
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 ❑Somewhat limited ❑Adequate ft x ft
D. INSPECTION Date Inspector
i
ONo evidence of failure 0..vi�ence of failure CIE vid ence f seasonal failure
--------------------- -------------- ---- - --- - --------------------------- ----------
(Indicate North)
cn
HOUSE
----------------------------------------------------- ------------------------------------------
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
IlMetal ®Concrete ®Plastic
B. Type of abkorption area
1. Fields ft. 2. Pits 3. Gallies
(i)- Indicate --setbacks, --front street, backyard, a-n-d-s-i--die- 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
®PWS ®Shared well
CONISIENTS:
REPAIRS ONLY:
As Built Inspection Required:
Status:
I'n ii Gal well
®Drilled ®Dug ®Casing above ground
As Built Submitted:
As Built Inspection Done: Inspector: