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HomeMy WebLinkAbout0831DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24.18 -1 -4 BOX 9 1 11 1 NONNI AN 1 1 or IN I IN IN a 00831 q� YES PUTNAM COUNTY HEALTH DEPARTMENT i , DIVISION OF ENVIRONMENTAL HEALTH SERVICES [�DL 'lI!Y f PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR p Jv VO Internal Use Only PERMIT # 9 - I Y epair Permit issued in last 5 years eDelegated ot in Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION 4// LI r� 6 TOWN cvt ` -e ✓ ,o' TM #37.L'&7o 2 L% OWNER'S NAME � c � ° PHONE # `% I MAILING ADDRESS 2 APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE ,I l � FACILITY TYPE J -Be ol , 00,i) GAA151HD COMPLAINT # PROPOSED INSTALLER C/Od -ey e V a��v ;�� , PHONE #a `�5-GSG-�S %`��l ADDRESS PC Ap a1 M3 �' .�,.,,����, REGISTRATION /LICENSE # Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 I I' 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. _r�93 f l _'!ii} �ali l . "1 ..; '�� , ':Y'• °4 T'4t�- f`_..1 :1 e:1 a\ +� _`�© K e? r.ii[S c,,., a�•i" I, as owner,a a to conditi ns stated on this form SIGNATU TITLE DATE 17 �e (owner) I, the septic inst , ler, agr a to c ly with the conditions of this permit for the septic system repair , SIGNATU 'ITL DATE Z (installer) ` Proposal approved with 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 backfilled until authorization to do so has been obtained from the Department. WIrcouAI I ICC llul V 11\ 1 b.111\ _ --- V V I Proposal Approved Proposal Denied ❑ Inspector's Signature & Title Datit Expi ati Date ,Repair proposal is in compliance with applicable codes Yes Lg No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information must bed � completed prior to any scheduling. Date: %/ Engineer or Firm: Phone #: 9115 l5'6 ' %5 7q'1 SPerson to Contact: L �u, —.� C�JV'G/l�P £''- ❑ New Construction Repair Pr�m ❑ Addition Program Reason: ❑ Deeps ❑ Percjs ❑ Pump Test Road /Street: Town: Mf� ee-s e / Tax Map #: ��• %� °/ 1 J Subdivision: Owner: FV-e ❑ Project not within NYC Watershed Lot #: NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTLNG YES NO ❑ ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner reservoirs. ❑ ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ ❑ Proposed SSTS within 300 feet of a watercourse or a DEC wetland. ❑ ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for Feld testing with the Design Professions and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY 1 DATE: COMMENTS: -3 Req.for field test:kly 4/16/2009 • Y PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information must bed � completed prior to any scheduling. Date: %/ Engineer or Firm: Phone #: 9115 l5'6 ' %5 7q'1 SPerson to Contact: L �u, —.� C�JV'G/l�P £''- ❑ New Construction Repair Pr�m ❑ Addition Program Reason: ❑ Deeps ❑ Percjs ❑ Pump Test Road /Street: Town: Mf� ee-s e / Tax Map #: ��• %� °/ 1 J Subdivision: Owner: FV-e ❑ Project not within NYC Watershed Lot #: NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTLNG YES NO ❑ ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner reservoirs. ❑ ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ ❑ Proposed SSTS within 300 feet of a watercourse or a DEC wetland. ❑ ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for Feld testing with the Design Professions and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY 1 DATE: COMMENTS: -3 Req.for field test:kly 4/16/2009 NOV, Swamp 12563 "Ir %\Ib Mendel Pond 164 TO , 14 o 62 -C P . ...... .... ... A� MUM me Lake Charles 22 T 0 0 -Mount Ebo .0 Corporate BREWS R FIS owa D.Ug S az KO •Rl J n SION 3 LA �, rs o Come, Pond ff'- R ED ............ ....... v II n 54 Old rcSoutheast Chuh 312 o CAM o LOOK 'em o A y Cem awster PxL PL Bq 'B roo k X 6 e)toir I/t • N Cam R KO •Rl J n SION 3 LA �, rs o Come, Pond ff'- R ED ............ ....... v II n 54 name project date tasks ZU04 .11160. — ell 70 C)IJ 74-,, Z-.?— 'PO-4eq-5d.-;,4 / WA 2,4t, I,? , I -r� I -IZ - 2-3 /� C2� 4vtA&k rl Y- vTN,q OV N� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: W „��,,� /� 1�, "7a i/ Address: 09 1-- 'jZ+ Located at (street): TM # __29. / °9 -- / — el Municipality: Watershed:��iZ SOIL PERCOLATION TEST DATA Witnessed by: •a Date of Pre - soaking 41 // Date of Percolation Test: Zz r Hole No. Hole depth (Inches) Run No. Time Start —Stop Elapse Time (m1 °') Depth to water from ground surface (inches) Start - Stop Water . level drop 1° inches Percolation Rate min /inch 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Notes: 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 min/inch, <2 min for 31 -60 min/inch). All data to be submitted for review. Depth measurements to be made from top of hole. Forth DD -97, pg I of 2 DEPTH HOLE # G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5'M . s! 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE # HOLE # HOLE # HOLE #. Indicate level at which groundwater is encountered 41©,�%' Indicate level at which mottling is observed /% Indicate level to which water level rises after being encountered Deep hole observations made by: I j�zr�) Date 1 Design Professional Name: Address: Signature: Design Professional's Seal Revised July 2013 A�be- Vow, yY I eIS ) (Se-e-, ,.ri F- 70� N Pal oij cor►c, block ce 0 tie 3 3 0