HomeMy WebLinkAbout4294DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www. s c a n y o u rd o cs . co m
631- 589 -8100
83.83 -1 -36
BOX 32
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04294
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PUTNAM COUNTY HEALTH DEPAR ENT MIX
DIVISION OF ENVIRONMENTAL HEALTH SERVICES L T!
'Mb�A FORS DISPOSAL SYSTEM REPAIR
OWNER'S NAME rA#1VQ.5 ICI e ,� &, Him 57L� -
SITE IACATION L/5 MDR iz ss .r,:_ u Da'. TO
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MAILING ADDRESS
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.) ,p
DAM TYPE FACILITY 45
PROPOSED im 'ILA— PHONE Sa26
REGISTRATION #
ell (include sketch locating all adjacent wells):
Nam: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal fran licensed professional engineer or
registered architect.
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Inspector's Signature &
Proposal Disapproved
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 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 agent of owner agree to the above conditions.
SIGNATURE � TITLE �6 �C DATE
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PUS: Hhite (EM); YeUnw (un EU; Pink Lzgliawt)
PC —RP 97
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PUTNAM COUNTY DEPARTMENT OF HEALTH -
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDTVUDAL ADDITIONIREPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project '° S� % ���'� S ' j �i (T)(V) V TM-
Year of Construction Size of Parcel
SECTION'B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling []Steep Slope ❑Gentle Slope ❑Flat
2. ❑Evidence of wetland Clow area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
NO
J. Property lines evident? U ❑ ..
4. Water courses exist on, or adjacent to parcel: ❑ L�
5. Existing individual wells within 200ft of the existing SSTS? lJ ❑
SECTION C. EXISTING SUBSURFACE SENVAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. ❑Level UGentle Slope ❑Steep slope
B. ❑Well drained ❑Moderately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited 1ySomewhat limited ❑Adequate ft x ft
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D. INISPECTION Date `� Inspector z =_
0:'o exidence of failure ® of failure ®Evidence of seasonal failure
------------------------------------ - - - - -- - -- ------------------------ - - - - -- ;
(Indicate North)
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(1) Indicate location of SSTS
A. Size and type of septic tank gallons
IlMeW 11oncrete 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. EXISTI\i TG WATER
CIPWS 13Shar ed well
CONS SENTS : C '
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REPAIRS ONLY: Status:
As Built Inspection Required:
SUPPLY -
❑Individual well
[Trilled C]Dua'
. ®Casing, above ground
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As Built Submitted:
As Built Inspection Done: . Inspector: