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---.-DIVISION OF ENVIRQNMpq= HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S .NAME PHONE 5X(0—,3?,9G
SITE LOCATION T14#
MXIIM%r.7 ADDRESS
PERSON INTERVIEWED co PPCMHMD Complaint #
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Nib,& 1 Relationship U. e, tenant, etc.)
DATE f7-1-22-2q <!!!9 TYPE FACILITY S
PROPOSED INSMIFM 4AeaQLJ PHONE q14-�142--0.50C)_
REGISTRATION # Z79
.Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal systen.
Different location may require submittal of proposal fran licensed professional engineer or
registered architect
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FT 71, J` 70QA:F.#IFM
Eka/541-1 /<CCJL PIT-
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Inspector's Signature & Title
1 Disapproved
Date,,---
roposal 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 Nam, Town and Tax Map number.
c. location of installed caqponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 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 own e; agree to the above conditions
SIGN TORE TITLE 7--
%hite (P M; Yellow Mm Eff); Pink (Aq2lavzt)
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PUTNAM COUNTY DEPARTMENT OF HEALTH -
DIVISION OF ENVIRONMENTAL.HEALTH SERVICES
INITIAL INDIVUDA.L ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project (,V e5l�_ Pi (T)(V) TM#
Year of Construction Size of Parcel
SECTION •B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling USteep Slope 36entle Slope [)Flat
2. �Evidence of wetland []Low area subject to flooding UBodies of water
❑Drainage ditches Mock outcrop
3. Property lines evident?
4. Water courses exist on, or adjacent to parcel:
5. Existing individual wells within 200ft of the existing SSTS?
YES NO
0
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. []Level 01.4entle Slope ee slope
P e P P
B. ❑ Well drained laModerately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Ar ea available for SSTS. (Primary & Reserve)
3-Extremely limited ❑Somewhat limited ❑Adequate ft x ft
D. INSPECTION Date Inspector -
ONo evidence of failure ntv-i'denceof failure ®Evidence of seasonal failure
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HOUSE
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„(1) Indicate location of SSTS
A. Size and type of septic tank
Illetal " OConcrete
Gallons
OPlastic
- -- - - --
(Indicate North) /
s
n =- ------------ ----- - - - - -- --
B. Type of absorption area /
1. Fields ft. 2. Pits ✓ 3. Gallies ft.
... -.. .. , -..o.. a,. ..:...cy -: _� e'�v -..... —.�, -V r o .•.¢F ++ICacrr+,.. ........ ...._ -.... _�, .,, -.veY. .�..
(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
DPWS ®Shared well
COMMENTS :
REPAIRS ONLY: Status:
0141vidual well
LL-Mriiled MDua'
As Built Inspection Required: As Built Submitted:
As Built Inspection Done: Inspector:
Casing above ground