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BOX 18
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01951
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OWNER'S NAME ev t Z e--ro k S d t 0 Jv54 .v PHCNE 20 Z SSZ
SITE LOCATION io�JE S?oN 47 C—AUA! A/• �1 - 36•ZS° l -Sr
MAILING ADDRESS AlCui F ,+,AF i t- ,d C7- • o l a, Z
PERSON INTERVIEWED PCHD complaint #
Name & Relationship (i.e, owner,tenant, etc..)
DATE TYPE FACILITY
PROPOSED INSTALLER PHA
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Diffeient'location may require submittal of proposal from licensed professional engineer or
reaistered architect. f
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Proposal approved, Proposal Disapproved
Q 2
Inspector's Signature & Title to
Iroposal 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 canponents 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 perf?d�d in accordance with the above proposal and conditions.
I, as owne:r,01or repor
SIGNUME l
of owner agree to the above conditions.
tP RI: %kite (M); Yellcow (= HO; Pink (Apphlaat)
PC -RP 97
TITLE o wgZ7f -- DATE 1 d r l
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Approval is hereby given to:
TOWN-ORNEW FAIRFIELD7" °-.. "',"
Septic Management Program
PERMIT TO DISCHARGE
RUIZ HECTOR L +STRYDIO SUSAN
6 KINGSTON RD
NEW FAIRFIELD CT 06812
to discharge to a subsurface sewage disposal system located at the following location:
KINGSTON RD 6 Map - Block - Lot 35 21
in the Town of New Fairfield which will receive treated domestic sewage from the dwelling
PROVIDED: 1. Liquid discharge volume shall not exceed 150 gallons per
bedroom per day_
2: The septic tank must be inspected regularly and be cleaned not
less frequently than every three years.
-=----------------------------------------------------------------------
------------------------------------------------------------------------
Inspected by: BW _. .... _ . _. _ _...._ _....... _
Issued : b Y
Issuance Date: 10/11/95 Expiration Date: 10111/98
SPECIAL REQUIREMENTS OR RESTRICTIONS:
1. Water conservation measures must be strictly adhered to.
2. The use of garbage disposal grinders is strictly prohibited.
------------------------------------------------------------------------
EXCEPTIONS:
HEALTH & SANITAON DEPARTMENT
"�:..
TOWN
'`.
se- .OF;NEW;FAIRFIELD
NEW FAIRFIELD:, CT 06812
' Tel:.746 -8145
POTENTIAL SEDER AREA: DATE:
NON -SEWER AREA;
INSPECTOR:
OWNER:
4
e + S 0 'o 4n• LAST ;.PRECIPITATION:
ADDRESS:
LAST "PUMPING:
MAP 3 •S' BLOCK : LOT: OWNER PRESENT VQ S
# OF BEDROOMS:
SEPTIC REPAIR:.
# OF OCCUPANTS.:
AGE OF SYSTEM:
FOOTING DRAINS: ^_?E
SIZE OF TANK:.
.CURTAIN DRAINS:
LEACHING SYSTEM;.
BURIED LEADER .DRAINS:
_\fo Z AS- BUI :LT ON FILE:._
WELL : eS COMMUNITY
WATER: NAME
ADJACENT. WETLANDS:
No STANDING WATER:
i BARE LEDGE:
X2 S BURIED OIL TANK b y y e You h'
FAILING: SEPTIrC
GRAYWATER: FUNCTIONING:__
QUESTIONABLE PIPES:_
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.COMMENTS:
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