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BOX 17
01875
d
PU NAM COUNTY HEALTH DEPAWDEW /
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL Fit SERNGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME ..Jc,�.ry C,(ie �� a /�— PHQr1E v� 7 J - Silo lo/
SITE LOCATION SO3 A9 4�-7 c2� �! Ya 3 C.)
MAILING ADDRESS
PERSON INTERVIBaID PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE —/ D Z 27 TYPE FACILITY
_T
PROPOSED T=Zi P::�Lecc Ay.4 --*15 Him
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 fran licensed professional engineer or
registered architect.
Proposal approved Proposal Disapproved
Inspecto 's Signature & Title Date
Voposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Sub=mission 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' 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.
SIGNkTURE . %-� TITLE A45�� DATE
DPgS: White (MD); Yellow (fin HE); Pink 0421 snt)
Pr-RP Q7
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITUL.INDIVIDUAL ADDITION / REPAIR FORM
SECTION A. GENERAL INFORMATION
Name of Proj eo�1 -� (� mm '3 TM4
Year of Construction
Size of Parcel - a� AcU
SECTION B., TOPOGRAPHY (Please check all appropriate boxes)
1. Milly DRolling OSteep slope [3 Gentle slope Zhlat
2. nEvi"dence of wetlands ow areas subject to flooding OBodies of water i
ODrainage ditches C Rock outcrops
YES -NO
3. Property lines evident? O
P
4. Watercourses exist on, or adjacent to parcel? �y
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. [Mvel Mentle slope OSteep slope
B. OWell drained Moderately well drained ht
omewhat poorly drained OPoorly drained
C. Area available for SSTS. (Primary, & Reserve) ,
nExtremely limited nSomewhat limited Adequate
ft x eft
k
a a. , '
D. INSPECTION"' Date d l Inspec #or .
❑No evidence of failure rlvidence of failure P�videnqe of seasonal failure
------- - - - - -- ------------------------------------- --
(Indicate North)
rye- HOUSE
cl
------------ ---------------------------------- ,`
(1) Indicate location of SSTS
t
A. Size and type of septic tank gallons
❑Metal oncrete P ~.
B. Type of absorption area
1. Fields o ft. 2. Pits 3. Gables 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
OPWS,
OShared well
dividual well
oDrilled
DD, ug- .- OCasing aboveground ' .
COMMENTS :
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7 S