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BOX 36
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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:.