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BOX 18
02007
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OWNER'S NAME
SITE IDMTION
MRIGING ADDRESS
PERSON INTERVIEWED
DATE 05,f 1
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.e, owner,
PM I l LI reg?q
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PCHD Canplaint #
ant, etc.)
-� LL TYPE FACILITY TT`vr►t
PROPOSED INSTAI. M' Spe; <s PHONE
REGISTRATION # G 'U
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.
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Proposal approved Proposal Disapproved
s sionature &
Proposal 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, epo t f owner agree to the above conditions.
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SIGNUE)RE TITLE 61--1 �1 DATE
Qom: %bite MV; YeUcw (4btm BL); Pink (ARaliau t)
PC -RP 97
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PUTNAM COUNTY DEPARTIMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITLAL INDIVIDUAL, ADDITION /. REPAIR FORM.'
SECTION A. GENERAL INFORMI A.TION
Name of Project (V)L
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. 011illy Clollina ,USteep slope aGentle slope 0Flat
2. ClEvidence of wetlands Clow areas subject to flooding Chodies of water
DDrainage ditches DRock outcrops
YF-S NO
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3. Property lines evident? __�.....�..._....
4. 'Water courses exist on, or adjacent to parcel? ❑ ❑�
5. Existing individual wells within 200ft of the existing SSTS? `` ❑
SECTION C.. EXISTING SUBSURFACE SENVAGE TREATMENT SYSTEM (SSTS)
1. Physical character of existing SSTS area.
[]Level A. []Gentle slope clti-e-ep slope
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B. OWell drained []Moderately well drained
13Some what poorly drained r1o.orly drained
- C. Area available for SSTS. (Primary.& Reserve)
DExtremely limited "Somewhat limited dequate ft x ft
}J P
Inspector
D. INSPECTION Date
ONo evidence of failure OEvidence of failure ClEvidencd of seasonal failure
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HOUSE :�
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(1) Indicate location of SSTS
A. Size and type of septic ctta
' nk gallons
Metal LJ Concrete ' Plastic
B. Type of absorption area
1. Fields % ft. 2. Pits 3. Gallies ft.
(2) Indicate setbacks; front street; backyard; and side yardrd- drmenion� -
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(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
13PWS IShared well Individual well
ODrilled ODug U Casing above ground