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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES I r
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR VV
OWNER'S NAME PAU L. A • FAr=NZ A PHONE Sol8 - 3079
SITE LOCATION 'IlYj 84 - I _ a
MAILING ADDRESS 175 PEEKSK ILL H OL-LOW P0J':$ V T NA K Y AL-t r y w1 % -f7c/
PERSON W N E R PM Complaint #
ame & Relationship (i.e, owner,tenant, etc.)
DATE G � 1_4 q- TYPE FACILITY Q BR COLONIAL.
PROPOSED INSTALLER I� �
0 Y PHONE 73c/ — 2-9 Z S—
REGISTRATION #
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.
lV W Dada �i L P E— C-AS7- 5L-Pr1 L 1^4 bl l<
z 14-d ' 61C l )� J41 5G (97I6- Lq J1 Wlt9r,
Proposal approved - Proposal Disapproved
Inspector's Signature &
Da
'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 Name, Town and Tax Map number.
c. Location of installed cagments 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, or reported agent of owner agree to the above conditions.
SIGNA ,o
TURE 1` TITLE OGtJIVWP . MM 0618319 9
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PUTNAM COUNTY DEPARTMENT OF HEALTH =.
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFO%MATION
Name of Project / G �7-3 ��� (T)(V) Tvl
v
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
I'
1. ❑Hilly ❑Rolling ❑Steep Slope ent a Slope ❑Flat
2. ❑Evidence of wetland ❑Low area subject to flooding . ❑Bodies of water.
❑Drainage ditches ❑Rock outcrop
YES NO
3.
Property lines evident?J
P y
4. Water courses exist on, or adjacent to parcel: U
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. ❑Leve lope C3 Steep slope
B. ❑Well drained C3 Moderately well drained
[]Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary�sery
❑Extremely limited ❑Somewhat limit ❑Adequate ft x ft
J . --
..� .. �.o.•. -�.q. C. «'�A'.0 �.' � � _ ¢!°•- - .. ... _ �.,..: .-�- � '��• •r � y •• � �'- e:9•JP• � "v 'a1 sy. - S. _ ?.. a� - e O,
D. INSPECTION Date .> Inspector
7
ONo evidence of failure ®Evidence of failure ®Evidence of seasonal failure
------------------------ - - - - -- ----------=---------------------- = - - - -- -- ------------ - - - - --
_Indicate North)
C/�I
Ci7
(1) Indicate location of SSTS ...... _ .. ..
A. Size and type of septic. tank
01\16tal-
0 r e
B. Type of absor Ion area
1. Fieldsmr 2. Pits
Y
HOUSE
gallons
nPlastic
3. Gallies ft.
(2) indicaie seMaicks; 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
CIPWS []Shared well Z n ivI uahwell
DDrilled Clu0 ® above ground
CONi S ENTS :
REPAIRS ONLY:
As Built Inspection Required:
As Built Inspection Done:
Status:
As Built Submitted:
Inspector: