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04322
PUTNAM COUNTY i HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL .HEALTH SERVICES_
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME pa u i jN_lu9i1 PHONE X23Z-
SITE LOCATION TKi Q(/_ --1 . z
MAILING ADDRESS I -* S(4 ffP- .
PERSON INTERVIEWED �'iWA)b%2 PCHD Complaint # -
Name & Relationship (i.e, owner,tenant, etc.)
DATE Jq TYPE FACILITY r
PROPOSED INSTALLER Z- O- OKaXJi d'�a In PHONE 9-36 A/1-3
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.
Proposal approved.
Inspector's
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Proposal Disapproved
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'ro o�sal 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, or reported agent of owner agree to the above conditions.
SIGNATURE (N TITLE OV /J Q DATE $ 9
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y PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVIDUAL ADDITION 1. REPAIR FORM
SECTION A. GENERAL INFORMATION
Name of Project Lt/ P t'-57:2 (T)(� �y TMg
Year of Construction / -5 `r Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. Offilly DRolhg ❑Steep slope Gentle slope OFlat
2. []Evidence of wetlands OLow areas subject to flooding Clodies of water
DDrainage ditches DRock outcrops
YES NO
3. Property lines evident? ❑
• ° --= �4: r 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.
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A. 11evel. Gentle slope . ❑Steep slope
B. OWell drained Moderately well drained
❑ Some' what poorly drained [loorly drained
C. Area available for SSTS. .(Primary, & Reserve)
ClExtremely limited ClSomewhat limited ltdequate
ft x ft
D. INSPECTION l - - Date Inspector•
0No evidence of failure . ClEvidence of failure . Evidence of seasonal failure
C/]
• - - - - - - - - - - - - - -- - i -- - . - - - -
(Indicate North) .
y
HOUSE -{? )( S
-------------------------------------------------- - - - - --
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
Metal ❑Concrete C]Plasti*c'
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 f well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams /wetlands)
SECTION E. E39STINC WATER SUPPLY
CIPWS
COMMENTS:
Shared well ClIn d-ividual well
13Drilled ®Dug Masing above ground