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BOX 18
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02085
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OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL .HEALTH_ SERVICES .
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE �/� �p� TYPE FACILITY R
PROPOSED INSTALLER as P PHOa�03J7z 6' %?fb
REGISTRATION #
Proposal (include sketch locating all adjacent wells): y
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.
�z
Proposal approved Proposal Disapproved
's Signature &
oe
bafA
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 canponents 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,.yas owner, or reported agent of owner agree to the above conditions.
SIGNAT' TITLE DATE ' /lam ,9`e
CP1 ": *dte MGM; Yellow (kn HI); Pink (Applicant)
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL .HEALTH_ SERVICES .
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE �/� �p� TYPE FACILITY R
PROPOSED INSTALLER as P PHOa�03J7z 6' %?fb
REGISTRATION #
Proposal (include sketch locating all adjacent wells): y
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.
�z
Proposal approved Proposal Disapproved
's Signature &
oe
bafA
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 canponents 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,.yas owner, or reported agent of owner agree to the above conditions.
SIGNAT' TITLE DATE ' /lam ,9`e
CP1 ": *dte MGM; Yellow (kn HI); Pink (Applicant)
i 377 366 Q
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O 5 wide rool ov han _
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FAIRF ELD ( 50' wide / DRIVE
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SURVEY OF PROPER Y
PREPARED FOR
THOMAS F/ TZGERAL D
3 71# BEING
LOTS 367-,376. INCL.
SHOWN ON
"MAP OF PUTNAM L AKE "
S/ TUATE IN
TOWN. OF PA T TERSON
PUTNA M COUNTY, NEW YORK
SCAL L
Said mop filed MorCh 20, /95/ as Mop Ns 149
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hedge row -
po/e B wires -
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TM PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVIDUAL ADDITION / REPAIR FORM
SECTION A. GENERAL INFORMATION
Name of Prc jec .� -add l (T)(V) TM#
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. 011illy ORolling r3Stee-p slope Gentle slope 13FIat
2. nEvidence of wetlands Low areas subject to flooding ClBodies of water
Mrainage ditches Mock outcrops
3. Property lines evident?
4. Water courses exist on, or adjacent to parcel?
5. Existing individual wells within 200R of the existing. SSTS? U U
SECTION C.. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM.(SSTS)
1. Physical character of existing SSTS area.
A. OLevel "en a slope OSteep slope
B. OWell drained Moderately well drained
OSomewhat poorly drained nPoorly drained
C. Area available for SSTS. (Primary & Reserve)
J�J Extremely limited ClSomewhat-
limited nAdequate
ft x ft
D. INSPECTION J: �y Dates . Inspector ;
nNo evidence of failure DEvidence of failure ®Evidence of seasonal failure
------- - - - - -- ----------- - - - - -- ---------------------
(Indicate North)
HOUSE
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t17 .
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(1) Indicate location of SSTS
A. Size and type of septic tank gallons
Metal c ete CIPlastic,
B. Type of absorption area
1. Fields ft: 2. Pits 3. Gallies ft.
r
(;)_Indicate setbacks,_ front- street. ackvarI d. and side yard_dimension ,.._'__: ...:_. _G:
(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
DPWS fthared well
dual well
MDrilled Mug
COMMENTS :
OCasing above ground
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