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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
`:SECTION A: GENERAL INFORMATION
Name of Project / / O . L& �c... Or, (T)M.
Year of Construction
PJ TM#
Size of Parcel 5v",
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling []Steep Slope ❑Gentle Slope Cl lat
2. ❑Evidence of wetland Clow area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
3. Property lines evident?
n • •--- - - � • 4: water courses "e7cist on; or a "djacent to parcel:•
nE NO
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. Me vel ❑Gentle Slope ❑Steep slope
B. ❑Well drained Moderately well drained
LJSomewhat poorly drained OPoorly drained
C. Area available for SSTS. (Primary & Reserve)
UExtremel limited CIO limited ❑Adequate ft x ft
Y -
do-V
7
D. INSPECTION Da te
Inspector
ONO evidence of failure. UfEvidenceoffailure nEvidence ofseasonal failure
- ---------------------------- -----------------------------------------------------------------
(Indicate North)
rii y
tri HOUSE
<�5
------------- ------------------------ ---------------------------------------------- ------------
(1) Indicate location of SSTS
A. Size and type of septic tank
gallons
®Metal OConcrete ®Plastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallies ft.
(2) Indicate -s'e ac -s, front street; Vadlk*d, and side yard d imensions
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 0Shared well CIndividual well
®Drilled ❑ ®Casing above ground.
COMNMNTS: c,4;e— 's a
REPAIRS ONLY: Status:
As Built Inspection Required: As Built Submitted:
As Built Inspection Done: Inspector: