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HEALTH DEPARWENT
PLfl'NAM COUNTY � � D
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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PHONE
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Pan) Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY �2 0 y 4�- (4<
PROPOSED INSTkZM Sqf V 0- VA -r-1 C- PHONE
REGISTRATION #
Proposal (include sketch looting 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.
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Proposal Disapproved
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roposal approved with the following conditions:
1. Procurement of any Town permit, if apple blca e.
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' diem. x 6' deep
drywalls 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 r rted ag t of owner agree to the above conditions.
SIGNATURE TITLE C 471u�- DATE
0 '11,5: White MD); Yellow Mkn BI); Pink (Applicant)
PC -RP 97
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OWNE9
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PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PHONE 11 ?- . 3 3 9r
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 Proposal Disapproved
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 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 TITLE; DATE o2
PIES: WAte- (PQI)); YeLlcw (Tom ED; Pink (Aaplant)
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project 1 t &I ` T l' TM#
Year of Construction Size of Parcel Lle,5s 1 Ac
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. Di-iiuy 171Rouing OSteep, Slo e.t : JGentle Slop e DFlat
2. ®Evidence of wetland ®Low area subject to flooding ®Bodies of water
®Drainage ditches ORock outcrop
YES NO' — Kto r-
3. Property lines evident? ® 0
Fe,nt to pardel:-
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. OL6evel ®Gentle Slo e OSteep slope
B. ®Well drained Moderately well drained
OSomewhat poorly drained OPoorly drained
C. Area avail ble for SSTS. (Primary & Reserve)
xtremely limited OSomewhat limited OAdequate �`�ft x
D INSPECTION Date.. �
Inspector
Mo evidence of failure ®Evidence of failure ®Evidence of seasonal failure
4
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(1) Indicate location"bf SSTS p-�
/CJ
A. Size and type of septic tank �� ' 1g ons
K al Concrete �Plast]
B. Type of absorption area
1. Fields .� ft: 2. Pits 3. Gallies ft.
is-_%O,
..: �2). Indicate setbae? {s, zont street: a-c yard, anal 'side yard di Tensions - _
(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
well gindividual ®PWS ®Shared w well
DDrilled Dug InCasing abo-Ve ground
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COMMENTS : "o 1, oe, f " F "rW+rVt 5 -T-0
REPAIRS ONLY: Status: � J
As Built Inspection Required: As Built Submitted:
As Built Inspection Done: Inspector:
(addrep)