HomeMy WebLinkAbout4073DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.67 -1 -11
BOX 31
I
III
I
'
a 0 '� q.11
j
III
17
1
1161
I
IF
■
`i
�'
L
70
lb
04073
OKWMI S NAME
SITE IACATI%
PUTNAM COUNTY HEALTH DEPARTMENT
FN iIRCNMF'E AL: LTEi ,.S ICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
MAILING ADDRESS
PHONE ��(� 73S- 7 `E `f�-
TO 0%3.- Ool000l -oil
mv�lfl
PERSON INTERVIEWED Pa iA-,,a Fay, O W r4a (Z PCHD Caaplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER L e oN A"-i -4 S o N S PHONE
REGISTRATION #
Pro (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 pr 1 engineer or
registered architect.
Wf Jam' /`O�"► �/ � �/ � C
�L
fi�ry -rs
fet-
Proposal approved Proposal Disapproved
Inspector's Signature &
with the
conditions:
1=1r
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 ccmponents tied to two fixed points (e.g.,house corners).
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 conditions.
I, as owner, r reported agen of owner agree to the above conditions.
SIGNATURE TITLE O Lv N e e DATE ff - .8 -9 8'
�
'S: V&be (POD); Yellow (fin BI); Pink (Afplicent)
^PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVERONMENTAL HEALTH SERVICES
INITIAL INDIVIDUAL ADDITION / .REPAIR FORM
SECTION A. GENERAL INFORMATION
Name of Project / 1 r I (T) (V) TM# J 3
Year of Construction Size of Parcel ' f O 67.x' Iae
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. 011illy DRolling OSteep slope a tle slope nFlat
2. OEvi'dence of wetlands Clow areas subject to flooding OBodies_ of water
Mrainage ditches DRock outcrops-
3. Property lines evident?
4: Watercourses exist on, or adjacent to parcel?
5. Existing individual wells within 200ft of the existing. SSTS?
YES NO
� o
SECTION C.. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM (SSTS)
1. Physical character of g SSTS ea.
A. 11evel C]Steep slope
B. [DWell drained 0M__
oderately well drained
13Somewhat poorly drained nPoorly drained
C. Area available for SSTS. (Primary & Reserve)
MExtremely limited DS6mewhat limited MAdequate
ft x ft
d 1 Y
j /...%.
- D. INSPECTION ; •.. ir::. An. - Date spec r
ONo, evidence of failure
rtri
env
ence of failure DEvidence of seasonal failure
- - - - - - - - - - - - - - b - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
zv (Indicate North)
- lid
'HOUSE'
35
---------------------- /---r ---------------
. A f
(1) Indicate location of SSTS
A. -Size and type of septic tank gallons fG
JOMe—tal OCon.crete OPlastic,
B. Type of abso tion area
1. Fields / ft. 2. Pits 3. Gallies ft.
(2) Indicate setbacks front street, b4ckyar3, and yard dimensions; - -
(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 Cj Shared well
COMMENTS: f "
®Individual well
Drilled LJDug LiCasing above ground
r-