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02660
OWNER'S NAND
SITE LOCATION
FAX
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PUI'NAM OO�JN'1'Y HEALTH DEPAE�Il�TP
DIVISION OF ENIVIROMMMAL HEALTH SERVICES
PROPOSAL FOR SEKAGE DISPOSAL SYSTEM REPAIR
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MAILING ADDRFBS Cp�-A- la t y L
PERSON INTE RVIEt— PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE e` Sr TYPE FACILITY
PROPOSED INSTALLER ur ' PHOI�
REGISTRATION # 3�
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
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 components 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, as owner or reported agent of owner agree to the above conditions.
SIGMIVRE TITLE Yh IG�� -'�` DATE 1
QP�S: Write MM; Yellow (fin BI); Pink (Applicant)
U M- TY TMEENT" i HEALTH
TNA COUN '-DE.? AR
DIVISION OF ENVIRONMENTAL HEALTH SERVICES -
INITIAL...INDIVIDUAL ADDITION /REPAIR FORM
SECTION A. GENERAL INFORMATION
ON
Name of Project gyv) Tm# 3 –
Year of Construction - Size of Parcel - '
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑ ❑ [Steep slope ❑ slope ❑
2. ❑ of wetlands ❑ areas subject to flooding OB-9dies of water
❑ ditches Mock outcrop . s
YES
3. Property lines evident?
ourses exist -on, -or- adjacent
L�J ❑
X
'�5. Existing *individual wells within 200ft of the existing. SSTS?
SECTION C.. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM (SSTS)
1. Physical character of existing SSTS area.
A. ❑ ❑Gentle slope OSteep slope
B. ❑ drained CYModerately well drained
❑ poorly drained ❑ drained
C. Area available for SSTS.
Reserve)
❑Extremel y limited
;Somewhat limited
Adequate
— ft x4dR
No evidence of failure
or All(
Date
®Evidence of failure UEvidence of seasonal failure
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i(Indicate North)
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HOUSE
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(1) InTi—ce7te-15—c5tion of SSTS
A. Size and type of septic tank. /boo gallons
LJMetal gConcrete ®Plastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallies ft.
(2) Indicate setbacks, front street, backyard, and side .yard dimensions
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
SECTION E. EMSTEXG WATER SUPPLY
LJPws ®Individual C!Shared well well
Drilled UDug ®Casing above ground
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