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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENEAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME &T A C- Co 0 Fq- _ PHONE L l a - �iq0 -7
SITE LOCATION
MAILING ADDRESS � -t'TP M,$0�-i
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY RE .>
PROPOSED INSTALLER w /a-P-0 6 R 6 6£ R F PHONE -1;-a
REGISTRATION # /3S
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.
Proposal approved X
Inspector's Signature & Title
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Proposal Disapproved
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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 perfonred in accordance with the above proposal and conditions.
I, as owner, r reported agent of owner agree to the above conditions.
SIGNATURE TITLE i'�C DATE
3'1F5: Vbite (PCfD): YeUcw (Tam EI); Pink (APPUa3nt)
PHONE a _1q -��'�.
MAILING ADDRESS
PERSON EWID Pam) Complaint, #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLIIt l f/ . �� 7t��g „� �. PHA vZ 4
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.
V-0- Alr
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WR00OM-__--
Inspector's Signature & Title
Proposal Disapproved
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 owner, or re rted agent of owner agree to the above conditions.
SIGNATURE TITLE DAATE -!
QPg5: V&te MV; Yellow ffi); Pink Qaiiamt)
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PUTNAM COUNTY DEPARTMENT OF HEALTH -
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVtJDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORiMATION
NameofProject AC a0P -11— MV) 77C93otJ. TM# A. 3/
Year of Construction yrir Size of Parcel o? Yo k
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling ❑Steep Slope aGentleSiope ❑Flat
2. ❑Evidence of wetland ❑Low area subject to flooding ❑Bodies of water
❑Drainage ditches Mock outcrop POP— d`. P0- DP0-7y
YES NO
—3.--Property lines evident?
4. Water courses exist on, or adjacent to parcel: O
5. Existing individual wells within 200ft of the existing SSTS? O
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area. .
A. OLevel ❑Gentle Slope OSteep slope
B. OWell drained 0Moderately well drained
OSomewhat poorly drained OPoorly drained
C. Area available for SSTS. (Primary & Reserve)
Nxtrernely limited C3 Somewhat limited OAdequate ft x ft
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
®Metal OConcrete ®Plastic
B. Type of absorption area
- --1. Fields ft. 2. Pits
(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 OShared well 0Individual well
Drilled ODug Casi ng above ground,
COivENTS: �/d R +�6w4 � � /°� �1H�C CoLOweI- L
REPAIRS ONLY: Status:
As Built Inspection Required: As Built Submitted:
As Built Inspection Done: Inspector: