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BOX 24
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W. r
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02873
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'PROPOSAL > ±`OR'SI A90 DISPOSAi SYS`T`EM REPAh2_.. � ...._..�.
SITE LOCATION L-,A
OWNER'S NAME /
MAILING ADDRESS
OFFICIAL USE ONLY
TM# --3
PHONE S2_.(o
PERSON INTERVIEWED_ d 4--Z— ' PCHD Complaint # i
Name a atlons 'p I.e., owner, tenant, etc.
DATE G' TYPE FACILITY
PROPOSED ALLER PHONE
ADDRESS 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 from licensed professional engineer or registered architect.
I, as owner* re Orte agent of owner.agme to the conditions stated on this fbnp- -
n o
SIGNATURE w4j,&A Jl�.l'�! r "a i TITLE DATE
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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
/moo/'. ................._. _... ,
I
D. INSPECTION � Date -� �' �� Inspector
ONo: evidence of fail ence. of failure llvidencd of seasonal failure
-- :L•-- n - - - ------ -------------------------------------- dicateNorth)
Y ..
l +1 _
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(1) Indicate location of SSTS
A. Size and type of septic tank gallons
OMetal j C]Plastic
B. Type of absorption area
. Pit
1. Fields- ' , ft. s 3. Gallies ft.
-
(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
ELM
COMMENTS :
Ij Shared well 13Ind-ividualweu
(]Drilled []Dug 0 Casing above ground
PUTNAM COUNTY. DEPARTMENT OF HEALTH
bIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL 'I MDUAL ADDITION i. REPAIR FORM
SECTION A. GENERAL INFORMATION
Gr G'G/ �TMv ~�J
Name of Project (T M
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. Milly ORolling CISteep slope Gentle slope Chlat
2. DEvidence of wetlands []Low areas subject to flooding OBodies of water
IlDrainagre ditches 13R.ock outcrops
E
YES NO
3. - Property .lines eNidert ?.
4. Water courses exist on, or adjacent to parcel?
5. Existing individual wells within 200ft of the existing SSTS?
SECTION C. EXISTING SUBSURFACE SEZVAGE TREATMENT SYSTEM (SSTS)
1. Physical character of existing SSTS area.
A. ®Level O ntle slope 13Steep slope
B. MWell drained . Moderately well drained
OSome what poorly drained [loorly drained
C. Area available for SSTS. (Primary. & Reserve C
13Ex'tremely limited omewhat limited tAkdequate, ft x ft