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HomeMy WebLinkAbout1909DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.22 -1 -31 BOX 17 01909 .., I, : ���.. IN NIL .T_.T rd r IN „N Pi 4 ` IN ■ 1 01909 v OWNER'S NAM SITE LOCATION mob# 3G A-2 °♦ 3 / M ULM ADDRESS Z 'i- Ile, t i v ��, /�c'� %�r r� p � '�'7 l Z S-0,03 PERSON INTERVIEWED PCHD Cawlaint # Name & Relationship U. e, owner, tenant, etc.) DATE TYPE FACILITY PHONE — fy 7 ,? 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&mac- C,1- +eA•c -A CAI s Signature & r000sal aoaroved 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 d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. C (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 reported agent of owner agree to the above conditions. SIGNkTU tE TITLE 0 DATE G �( 0�g8: White (PM); YeU ow (fin HO; Pink (Alpliamit) PC -RP 97 SITE LOCATION MAILING ADDRESS oly ` PROPOSAD FOR' SEWAGE "DISPOSAL `S'YST94'REPAIR -" R,t,c f A 72- V ; -h . 1f.2 PHONE 2 ? 9 - J q 7J TO PM Complaint # Name & Relationship (i.e, owner,tenant, etc.) % TYPE FACILITY�vy, �� S � /2 r/1../ vNOf, F v %V C -- PHA 2-2j--6,)-7-? REGISTRATION # Proposal (include skeetic: 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: Erl Proposal approved Inspector's Signature & Proposal Disapproved //49 /X/-- -� P, � � I Date toposal approved 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 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 own , or reported agent of owner agree to the above conditions. y SIGNATURE" Iji TITLE XM: WAte (POI)); YeUcw (Tam ffi)i Pink (kj2l ent) D. INSPECTION Date j Inspector ❑No evidence of failure CI-Evidence of failure ❑Evidence of seasonal failure I V ---=-------=--------------------------------------------------- - - - - -- - - - - - -- - - - -- -- - - - - -- I (Indicate North) s � ++ �� HOUSE :�I�j (1) Indicate location of SSTS A. Size and type of septic tank gallons Oit9etal OConcrete OPlastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front stredt,- 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 [Individual ❑PWS ❑Shared well well OrDrilled ❑Dua Casing above ground 0 b D COvIvIENTS : �c, ,ti. P ss. le SS G r e c�,' t z r �f«., REPAIRS ONLY: Status: As Built Inspection Required: ' As Built Submitted: As Built Inspection Done: Inspector: (addreD) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORMATION Name of Project Z- 'L )m T TM# Year of Construction Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. ll ®Rolling OStee Sloe []Gentle Slope e ®Flat Y � P P P 2. OEvidence of wetland Clow area subject to flooding ®Bodies of water ®Drainage ditches C-3-Pock outcrop /k-- YES NO 3. Property lines evident? 4. Watercourses exist on, or adjacent to parcel: 5: Existing individual wells within 200ft of the existing SSTS? SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) L Physical character of existing SSTS area. a tle Sloe Stee A. ®Lev el ®G n p LJp slo e p B. Well drained L�Moderately well drained C3Somewhat poorly drained OPoorly drained C. Area available for SSTS. (Primary & Reserve) ®Extremely limited mewhat limited OAdequate -ft x ft