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BOX 22
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02562
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SITE LDMTIM
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MAILING ADMIMS ,�5,% / ,Sec, f2- e'W 7��G•/e['4 oat /� /Pd�% y.� //c y
PERSON INTERV3BM PCHD Capplaint #
Name & Relationship (i.e, camer,tenant, etc.)
GATE TYPE FACILITY S
PROPOSED INSTpLIER /,� tpc✓ x c. �''�- c - PHCNE
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. z -Iv40, 0vsr o•s,i
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Proposal Disapproved
Inspector's Signature & Title
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 eanponents tied to two fixed points (e.g.,house oorners).
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 oonditions.
I, as owner, or reported agent own gr to the above conditions.
SIGI�ZURE - — • jA TITLE � i�rr ✓✓ DATE
IM: Mite MD); Yellow 030 EU; Pink (Ailiamt)
Pr -RP 07
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVIDUAL ADDITION [REPAIR FORM
SECTION A. GENERAL INFORMATION
Name of Project
Year of Construction Size of Parcel ? Z 7
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1
1. 01-filly �g slope Mentle slope OFlat
2. 011"vidence of wetlands Clow areas subject to flooding 013odies of water
❑Drainage ditches ❑Rock outcrops
YES NO
3. Property lines evident? ❑
4. Water courses exist on, or adjacent to parcel? ❑
a
5. Existing individual wells within 200ft of the existing SSTS?
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SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM (SSTS)
i
1. Physical character of existing SSTS area.
A. Clevel. � Gentle slope teep slope
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B. Well drained Moderately well drained
ClSorne,
what poorly drained OPoorly drained
C. Area available for SSTS. (Primary. & Reserve) '
MExtremely limited OSomewhat limited 11dequate ft x ft
Mo evid ce of failure Chvidence of failure ClEvidence of seasonal failure
- --- - - - - -- ----------------- --- -. - - -- (indicate North)
HOUSE
H
-------------------------------------- ? -----------
(1) Indicate location f SSTS
A. Size and type of septic tank gallons
OMetal oncre Plastic ' Q -
B. Type of absorp on .
1. Fields its 3. Gallies ft.
(2) Indicate„setbkks; front-street; backyards -an si - ._w.....__
(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
PWS OShared well ell
MDrHled 0Dug OCasing above ground
CONS ENTS :