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SITE IDMTION 12' 040AJEey 14; t/ P L TO i3 . / 2 JL
MAILING ADDRESS f � e�so•y N�
PEWM M&MEWED O .v "ax— MM Camplaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE TYPE FACILITY ,S: - /v4 le—
PROPOSED DETALLER '�2e d.. I-i-D A-w�9 2"r✓ PHONE ate• s -�� a-3
REGISTRATION #
Prcpml (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.
- �'i19.S T/�-l/ ='�F! �r �� �s // v �e d,4 -a.. �i�i57`.r..► g
Proposal approved a Proposal Disapproved
s sianature &
c^
Dater-
'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
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 r��rted agent of
owner agree to the above conditions.
SIGNkZURE
TITLE_ piP.�
OAT'E �' 02O �%
MUS: Write (POD); yeUcw (Tam BI); Plink (AFp1jaw t)
Or oo n-i
�Y
PUTNAM COUNTY DEPARTMENT OF HEALTH s
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project )(V) TM#
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. ❑Hilly ❑Rolling ❑Steep Slope ❑Gentle Slope ❑Flat
2. ❑Evidence of wetland Clow area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
YES NO
3. Property lines evident? ❑
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 ❑Gentle Slope ❑Steep slope
B. ❑ Well drained ❑Moderately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited ❑Somewhat limited ❑Adequate ft x ' ft
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D. INSPECTION
ONo exidence of failure
U)
n
rn
Date ��///�/�Inspector
OEviZe ce of failure ❑Evidence of seasonal failure
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(Indicate North)
(1) Indicate location of SSTS
A. Size and type of septic tank
c3Ilietal Concrete
B. Type of absorption area
HOUSE
gallons
OPlastic
1. Fields` ft. . 2. Pits 3. Gallies ft.
(2) Indicate setbacks, 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
13PWS OShared well ( Individual well
DDrilled CIDu0 11 Casino above ground
COMSENTS :
REPAIRS ONLY:
As Built Inspection Required:
Status:
As Built Submitted:
As Built Inspection Done: Inspector: