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PUI'NAM COUNTY HEALTH DEPAR TKERr
DIVISION OF.ENVIRONENrAL HEALTH SERVICES
OWNER'S NAME
PHONE
-S;k C— 04
SITE IACATION
,341
AFL o S oe�+a �� �., C�
20 /
-3 0°- l F,- / -
MAMIM ADDS
PERM WrERVIEWED Q,/J1U e4^ PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY SyiN der tl �=
PROPOSED IlSSTALLER PHONE
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 Fran licensed professional engineer or
registered architect.
Inspector's Signature & Title
3.
Disapproved
cate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed canponents 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.
T'
(e.g. house corners).
three precast 6' diam. x 6' deep
System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or ported agent of owner agree to the above conditions.
SIGNATURE �
I16: V&te MV; Yellow (fin HI); Pink (AppLi®nt)
PC -RP 97
TITLE JA LO-15 DATE /A - caa -��
I
.
PUTNAM COUNTY HEALTH DEPARTMENT
PROPOSAL FOR SEWAGE DISPOSAL SYSTER4 REPAIR
atm ° S N*E PHONE dg'i o
SITE LOCATION 'M#
MAILING ADDRESS ^' L,4-A,21 I/ Al, 1, E Y, Al Y f ° s"7 .9
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITYar✓S£
PROPOSED INSTALLER A-GG PHONE �O F - C i6 s
REGISTRATION #
Pro osal (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.
Pti st ar L.I-rio a F A /000 ev�c Afgje Z/'T T.4" h-
r-
i
s Siqnature & Title
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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 (e.g.,house corners).
d. Systaa description (e.g., 1250 gal. concrete septic tank, three precast 68 diam. x 61 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.
as owner, or reported agent of owner agree to the above conditions.
SIGNATURE CZ/'� -rr-- TITLE
, , : In: 1: : totdte (PCFD) a Yel1cw (Tan ED o Pink (kjijamt)
DKTE
J
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b
� •: • � ' • I� 'ly `1�1' Mme,
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I I /
OWNER'S NAME D RW
SITE LOCATION I . &144 jPo i-ri�� C�s O`'L- T'rl f ^30°I
�,_.rs
MAILING ADDRESS PLCq 1 IA-6 i -e PU
PERSON naEmEww ID" Fig. -Iz et 1 o al rV e sP.- PC HD Caaplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY -� Rd
PROPOSED IMTA LER /-1-t4i -S c- PHONE a..;�,
REGISTRATION # �f
offal (include sketch lo6ating 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 fran licensed professional engineer or
registered architect.
rU S /9-4 •e. iC ct S 0
Proposal approved 1 Disapproved
Inspector.',s Signature & Title
Proposal approved with the following conditions:
1. Procurement of any Town permit, if apple blca e.
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. Sys 6m 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 eported agent of owner agree to the above conditions.
SIGNATURE -e— TITLE J0A-V5 DATE
OOPMW Hhite (PCIV; Yellow (fin ffi); Pink (nikent)
PC -RP 97
P�� D
FRED ADAMS, S, JR IVC.
691 F'Api1 E' XV Mll LS RD.
CAItMEL, N. Y 7 0 512
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v... PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL A.DDITION/REPAIR FORM
SECTION A: GENERAL INFOR'NIATION
Name f Project G T r
0 0j ()(V) TM ,
Year of Construction Size of Parcel '
SECTION B. TOPOGRAPHY (Please cheep all appropriate bores)
1. ❑Hilly ❑Rolling ❑Steep Slope Gentle Slope ❑Flat
2. ❑Evidence of wetland []Low area subject to flooding f water
❑Drainage ditches ❑Rock outcrop
I Property lines evident? ❑
_„4... -Water courses exist on, or adjacent to-parcei: ❑ '
5: Existing individual wells within 200ft of the existing. SST Y
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical'character of existing SSTS area.
A. ❑Leve e ope ❑Steep slope
B. llW'elldraine& drained
0somewhat poorley drained ❑Poorly drained
C. Area available for: SSTS— _(Primary
®Extremely limited what limited []Adequate/ ft x ft
T w
••: tLt�
D. INSPECTION Date Inspector
I evid
o ence of failure Mvidence of tfail e Evidence of seasonal failure
-------------------------------------------------------- 1
A (Indicate No ) /
Il .
y - `
Hogs_ �--
C +1 f..
ti
(1) Indicate location of SSTS
A. Size and type of septic tank' —` gallons
Metal crete ®Plastic
B. Type of abso i area
1. Fields , ft. 2. Pits 3. Gallies ft.
(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. EMSTIiIG WATER SUPPLY
[jPWS OShared well � Indivi ual well
CO1�l�IENTS : /
Mrilled Dug 0 Casing above ground