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00797
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
1=y—
EA S
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Nol Internal Use Only PERMIT #
❑ Repair Permit issued in last 5 years El Not In Watershed
❑,% Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
L�l ❑ _ Repair within 200 ft. of a watercourse or DEC - mapped wetland Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
1�@
I A r1—
1 TM # 4 �
PHONE 7ff_ cL
Name & Relationshipf(I.e., owner, tenant, i aar)
DATE i C> L) _ FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER �� PHONE #
ADDRESS �J �7 �S r `/� /�J REGISTRATION /LICE #%n
Ala �,`.� � •
Proposal (include 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 gpxt. ►e5 of the repair: / j S k f
:�. i 71 , ♦ i /,&-i .0 — —,-4ro % i't w[%G A ref . A9 .S/: I ( . ILM K r cA.&� 10 �
I, as owner,agree to the conditions stated on this
SIGNAT 'I
(owner)
I, the. septic installer, agrAe to comply with
tea--'-- t �
�l
In 540'e -tD Ca17UA�
DATE 8
ns of this permit for the septic ,system repair
SIGNATURE ITLE • U%t� %1VATE
(Installer)
Proposal aooroveA with the'following condi tons:
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 back-filled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Pr opo l Approve Proposal Denied ❑
I pector's Signature & Title Dati Ex ratio Date
,Repair proposal is in compliance with applicable codes Yes me"' No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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Environmental
Protection
New York City Department of Environmental
Protection
SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR
DETERMINATION
Pursuant to the authority granted under:
Article 11 of the New York State Public Health Law; Rules and Regulations For The
Protection From Contamination, Degradation and Pollution Of The New York City Water
Supply and Its Sources, 15 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR
Appendix 75 -A Wastewater Treatment Standards - Individual Household Systems:
Putnam County Septic Repair Program Plan — March 2005.
DEP Project# 1131� _ _ ____. PCHD Repair #� R_" ;730
Site Location: �3 �`4*�� ��' �" t— 1 `` T.M.#
Qq -Z-/9
Reason for Joint Review:
Drainage Basin 200' of WC /Wetland l✓ Repeat Repair in 5 Yrs.
Name of Owner: !,►'� •!q ti
s l
Owner's Address:
Drainage Basin of Project Site: �4s� �j/4h��
Installer•�`�",
/ T
General Description of Sewage System Repair:
• -------- ........... ......
- ----_.......... ..... .......... _.. ........ _ ....... . ......... . ...
.....
lei -S ki t
u
Dates of Site Inspections and Soils Tests: %�� /`lam „_,. �_?'1 _z', ..... ___. .......
_�_
Appruvcd____J _ `Incomplete Delegated._._ "''` Denied
__.....__��__.._
,'Required: Soils Tests___._ Repair Sketch WC /Wetlands Wells
":Reason
Determinat' n made by:
......... . ........ ... _ _...._ _.... _ ._....._...__.
Em ineeiin; Di��ision Date.
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December 2, 2014
0 Wetlands NYSDEC
1:4,012
0 0.0325 0.065 0.13 mi
Ij0 .1- 11 1 1 Tr' —ice I
0.05 0.1 0.2 km
Sources: Esri, HERE, DeLorme, USGS, Intermap, increment P Corp.,
NRCAN, Esri Japan, METI, Esri Chita (Hong Kong), Esri (Thailand),
Tan Tom, Mapmylrtdia, ® OpenStreetMap contributors, and the GIS User
Community
Putnam County ITIGIS
REBECCA Wn KNBERG, RN, BSN
Public Health Director
ROBERT MORRL% PE
Director ofEmiromnentd Health
DEPARTMENT OF HEALTH
I Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARYELLEN ODELL
County Esecu&v
TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
ATTN:
FROM:
PRIORITY - SEPTIC REPAIR
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
JOINT REVIEW
PROJECT:
LOCATION: 6
My
TOWN: TM # 2j,-9-1q
NOTICE OF COMPLETE APPLICATION: DATE: a' c�' /
❑ Within the drainage basins of West Branch, Boyds Corner, or Croton Falls
Reservoirs
❑ Within 500 feet of a reservoir, reservoir stem or control lake.
Within 200 feet of a watercourse or a DEC wetland and appearing on a
subdivision map approved after December 31, 1992
❑ Design flow greater than 1,000 gallons /day.
❑ Commercial SSTS.
SEPTIC REPAIR JOINT REVIEW
643 East. Branch Rd, Patterson.
24.
24-2-62A
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A,
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December 2, 2014
Wetlands NYSDEC
A111TO I.
/24.-2-60
35.-5-24
-23
1:2,006
0.015 0.03 0.06 mi
0.0275 0.055 0.11 km
Sources: Esri, HERE, Dekorme, USGS, Intermap, increment P Corp_
NRCAN, Esri Japan, METI, Esri China (Hong Kong), Earl (Thailand),
Tan Tom, Maprnylrda, 0 OpenStreetMap contributors, and the GIS User
Community
Putnam Counly IT/GIS
PUTNAM COUNTY DXPARTMENT OF HEALTH
DIVISION OF ENVIR011fNTAL HEALTH SERVICES
DESIGN DATA SHEET — SUBSWACE SEWAGE TREATMENT SYS -MM
Owner.
I.00tbd at (street): 6`13
mvewp>tlity:
AM
TM #
SOM PERCOLATION TEST DATA
. weed by: s
Date of Pre�oahlaE. Dab of Pereolatin Teel:
Notes:
1. Tests to be repeated at.same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < 1 min for 1 -30 mWinch, < 2 min for 31-60 miNinch).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Fam DD*7, pg l of 2
'FZW1' Pl'1' DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE # HOLE # HOLE # . 1
HOLE # HOLE #
G.L.
fl.5'
1.0'
1.5'
2.0'
2.5' VI
3.0'
3.5' Owl
4.0'
4.5'
5.0'
5:5'
6.0' TC C444
4 " f
70'
7.5'
8.0'
8.5'
9.0'
9.5'
10.0'
Indicate level at which groundwater is encountered
_... __.
Indicate level at which mottling is observed
N�
Indicate level to which water level rises aver being
encountered
Deep, hole observations made by:
�
Date i
Design Professional Name:
Address:
Signature:
Design Professional's Seal I
Revised July 2013
S4. .p T�- 'A
Q'0 00(- -] S I
piePsa 4 vo k ' U
Site Restorations Ilc
13013- 763 Millbrook,
NY 12545
Customer
43
AddressA, LKI
Phone 0q. 9640
Draining /Pumping Up to 1000 Gal. Uncovered.
Overage Per Gal. Gallons over 1000
Hand Dig Fee
Machine Fee
Heavy Sludge Fee
Snake /RooterNacuum
Enzyme
Notes /Remarks,
Date 2 z a
9A1 -9771
845- 249 -6768
I /Customer Authorizes SR Ilc to enter my property and I /Customer take full responsibility for
any damage SR Ilc may cause during operation on said property.
SR Ilc is not responsible for any damage on property or to any Structure wile SR Ilc is on site.
Customer Date
AL
W
i.
00
Putnam County Department of Health ,
Division of Environmental Health Services
SSTS Repair - Fin1 Si Inspection
Date:. petted by: %,1< si Installer: �u S /CG y
Street Loc n: a� . B eOwnen.
Town: rS Repair Permit i#: I -d -7i -/4/ TM # L
1.
Type of bystem: Uonventtonal NJ Alternate U Comments:
2. Sewfic Tank
Yes
No
•N /A
Cox ts
SA
r� s I
a. Septic tmk size ,0 1,250... other..
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
d.
L All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
iii. Minimum 2 ft. Original soil between box &
treuches
e. Jymsdaift- properly set ...........................
L TMRCM
i. Syst= completely opened for inspection
ii. Length required Length installed
iii. Poe slope checked ... ...............................
iv. Installed according to plan .....................
v. 10 ft. from property line - 20 ft- foundations ...
vi. Size of gravel % -1 '/, " diameter clean .........
vii. Depth of gavel in trench 12" minimum .........
viii. Ends capped .................... :..............
3. hnAm
a SETS Am located as per approved plans
b. Fill swdon-
c. Distance from water coursetwedands
4. Over$U Workmonahi
a. Boxes properly grouted and installed correctly ...........
b. All pipes flush with inside of box .........................
c. Back511 material contains stones <4" diameter .........
d. Curtain drain & standpipes installed according to plan
e. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. 'Erosion control provided ............................
Additional Comments:
USI Rev - 011312
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