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Home My WebLink About4176DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.75 -1 -31 BOX 32 04176 ' ;, L L . ...L ,tiI - 1. � T '. � or Z �. r ' ■ m k 04176 PUTNAM COUNTY HEALTH. DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES. PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME 1-b WAP-0 % EA60- 2L PH= 6.26-67 Si' SITE LOCATION 30 Xoeg/,SsLV DR, . tAf- -c PZkKsk, It ,, 1' 714# -7S — L MAILING ADDRESS (?% ©SG,4 k/�Mk ci Po 'TI Ak 64 c W 10 F"7 F PERSON INTERVIEEW—M PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE 1 �' 241 TYPE FACILITY 655 Z40 M.*2 CAr,Az C., PROPOSED INSTXJM go ju.+" 6g,4Ck/t4-- PHONE ,�20 -0259 SJ REGISTRATION # 13sl- 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. ► Sa-rm r. t-19 CaLAC.E 01,D STEZ-L - rF+iYkg wlTh3 /'lCvy laSo &A (_ (, &VC J. Erg C-I% M C 4,oct9-, -rr o 1W Proposal approved Proposal Disapproved 's Signature & 1161.) % Date oroposal 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 earponents 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, ?I reported agent of owner agree to the above conditions. SIGNATURE &4 TITLE (1j w "AA- DATE % J 2 OOPM: Hhite (PQHD); Yel1cw (fin HI); Pink Lk#iamt) Pr-pp Q7 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF E* NVIR0NINIENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORMATION Name of Project TM" Year of Construction Size of Parcel SECTION 1B. TOPOGRAPHY (Please check all appropriate boxes) 1. ❑Hilly ❑Rolling ❑Steep Slope ❑Gentle Slope ❑Flat 2. ❑Evidence of wetland ❑Low area subject to flooding ❑Bodies of water ❑Drainage ditches Mock outcrop Y NO e..... �..._. Property lines: evident ?. 4. Water courses exist on, or adjacent to parcel: ❑ ❑ 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. evel ❑Gentle Slope: ❑Steep slope B. ❑Well drained Moderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) ❑Extremely limited 13/Somewhat limited ❑Adequate ft x ft 4 u �q D. INSPECTION Date 7 Inspector No evidence of failure ®Evidence of failure ®Evidence of seasonal failure, Q J _1 Ell I --------------------------- =--- - - - - -- ------------------------------------- - - - - -- ---- - - - - -- (Indicate North) II 7_. A (1) Indicate location of SSTS A. Size and type of septic tank gallons IlMetal OConcrete OPlastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front street, backyard, and side 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 DP•WS . []Shared well ®Individual well DDrilled []Dua0 OCasing above ground CONI S ENTS : REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: