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HomeMy WebLinkAbout4818DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.34 -1 -7 BOX 36 IN NE 0, IN r `T6, 1 'L ± , �r r �. �I . ,s ' J. , . 1 � r �� ��~ ti .� . r• �• aa+• �,�• • •�� is 11 • • a • • is :10 7-M wa. MM'S NAM l R ,oA-r- ry 1n iQ s-r a ka v V PHCeE SITE MOTION L10 e r 1� R { WaLI M ADDRESS L w ka p a CZ )<S W,< <k l ® s ?'7 ! PERSON INI EWIEWED :- 80Tg=,ryc3 S V A;V 3 Z< 3 UdWyLv, or_ �O k of PCHD Canplaint # Name & Relationship (i.e, owner,tenant, etc.). i DATE TYPE FACILITY PROPOSED INSTAIJM /770TMs 564 wT VC.' PHONE REGISTRATION # Picoosal (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. /� n 600 LA ... <: _ .,. . �. ... - J. . �. a. Cleaner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,hcuse 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. SIB 42m�) TIME DATE , � � 01q Cf CPISS: Vbite (PCHD); YeUcw (2n ED; Pink (AFplicsnt) PC -RP 97 I I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL ADDITION /REPAIR �'tJRM SECTION A. GENERAL INFORMATIO \' Name of Project��' Year of Construction Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1.' 011illy: DRoll" Steep slope Gentle slope ®Flat ZD 2. DEvidence of wetlands Clow areas subject to flooding U of water DDrainage ditches Rock outcrops s YES NO 3. Property lines evident? -.... _... :. .,., _... ._ ..:ten :. ..:: - • D 4. Water 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. A. []Level CIG entl e slope eep slope B. DWell drained Moderately well drained DSoewm ha oorly drained OPoorly drained C. Area available for SSTS.. (Primary, & Reserve) llxtrernelylEted Somewhat limited Adequate ft x P �i i • .- �� n G "p n _. --ra ^�. _ _ �. � > t � c .. �. ' _ ' y�. -.- A G' � .vW �/i•�. ..� � sty .4..: D. INSPECTION Date Inspector UNo evidence of failure Evidence of failure ClEvidencd of seasonal failure . - - - -- -------------------------------- (Indicate North) HOUSE (1) Indicate location of SSTS A. Size and type of septi Se ns', Metal Concrete astic B. Type of absorptio ea , 1. Fields ft. 2. Pits 3. Gallies ft. Indicate setb front street backyard and' side yard dimension§ - (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 PWS ® Shared well UIndividual well ®Drilled (]Dug DOW Casing above ground COMMENTS:.