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Home My WebLink About0768DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -73 BOX 9 1 ru 17 r IS 1 ,r� i �; 1 ;I T If ' ' L r M T� ■■■ 11 .: E�St PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use Only PERMIT III fl- ❑ Repair -Permit Issued in last 5 years ❑ Not in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION a 6 RI— ala TOWN P a+f_tr,J 0y\ TM # OWNER'S NAME oY1 PHONE # MAILING ADDRESS _Sd_ M % APPLICANT 7ameJ q)�'&alo CxGu c/a 4-rrN c/ Name & Relationship (i.e., owner, tenant, contra r) DATE (?)�� o�� 0�1p lU _FACILITY TYPE /{- aMR__ PCHD COMPLAINT # PROPOSED INSTALLER .�G 1�2I �j�i.q �'�^+ �X PHONE #-I ADDRESS vC REGISTRATION /LICENSE # PG X31 fi l lU-? Pro sal pnclude a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. 0 I , 411 hr64y(z it' dl � s � � C r era. Pv0 Weil iY► Q- r - 11 ow t eS - 0DrK. N1 a.. r is I, as owner,agree to the conditions stated on this form - SIGNATURE � �„� TITLE�h.j`}r, l l2.1! DATEO� U (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE ,,�� TITLES ,S I �� DATE 0:1 a -0101 p (Installer) L/ tv Pro�l�or�� with the following conditions the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfil(ed until authorization to do so has been obtained from the Department. C INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ I pector's Signature & Title tO Date Expi tion Date Repair proposal is in compliance with applicable codes Yes O No ©/ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 -- - - wo 1',"�•,�'' n I� (� Ste° 1��_ _.. ____ ..�� _ _ ._ _ _ _ I t Ale wit I _ _I J 0 PUT' -42W, COUNTY DE -A,.RT_?VLENT OF HE A.LTHf DIY'ISION OF EN1%TRO 'ii /TENT- 4,L.HEALTH SERVICES. DESIGN DATA SHEET - SUBSURFACE SEU•°AGE TREATMENT SYSTEM Owner: (a (� . -.�.,� ' 12% S� .Address:- Located at ;street; :-2 a TM # Sectioni ?� Block Lot? 3 Municipalit }•: � U �'"— Watershed: �- SOIL PERCOLATION TEST DATA Witnessed b3- Date of Pre - soaking: LIO Date of Percolation Test: /.� / /�� • Hole No.. ` + I. Run No. i Time I Start — Stop. I Elapse p � Time ( (min,) I f I Depth to water from around � . surface (inches) Start. - St' I WPercolation Water I level drop i in inches. I ( � i Mate ! . miniinch ! ` I ! I 9 L, _ . b �01I 1 y � -K* 3 t. ,>{ Lt- I k ( I 4 I I I � 12 4 4 L i { 3. I { i 4 I I I j. i 3 4 3 i 1 I Notes: i. T°sts to De =e-at.-d ai same depth und, aCnrkomnatel,�' eaua oercoiatio*: rates are io- .min� nch. < = mir: i0l -o(: mi�ODtalned a: eac� peTCOla1UP -.es: CIOIe. < i mir ?ul data to be submitted for review. _. Death measurement; tc be mane from mr. ilt nnlr S� 10 V.,f ( ( u (hey kL fl L/'U 4p �i { OJIC o