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HomeMy WebLinkAbout0893DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.38 -1 -25 BOX 10 11:• ' I,y 6 I ,I 1' ' T Ar ' IA -. , 11:• PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES IR SITE LOCATION OWNER'S NAME C, L 0c M MAILING ADDRESS `7 vv "!'-0, OA PHONE # APPLICANT 0- Q Name & Relationship (i.e., owner, tenant, contractor) DATE �� �i 3 FACILITY TYPE QWA X4%PA, PCHD COMPLAINT #Offl'i9' iq PROPOSED INSTALLER cv-n PHONE # ADDRESS SILREGISTRATION /LI ENSE � C" / 9 1 �. 9r�- If -032. Proposal (include a separate sketch locating the house, property lines, all adjacent well witFiin 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 a ent of the repair. l i I, as owner,agree,t0 the con tions stated on this form SIGNAT , ` ~` ' TITLE 'L�lEI.� DATE (ow agree to comply with the conditions of this permit for the septic system repair i- - - -- - -- - - - ....— — -- SIGNATURE '— �`5c'w) ITLE DATE q /3 (installer) 6? CA A� � 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. 0 ner's name, Site Street Name, Town and Tax Map number b. Lotion 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 backfill until authorization to do so has, been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ Signature & Title is in compliance with applicable codes COPIES: PCHD; Owner; Installer PC -RP 99ML 3 D9) / E)(piratioKOai Yes No ❑ Rev. 2/07 Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site In ection 1-2 M �g o Date: 30 3 Inspected by: r� Installer: Street Loc tion: 7 , , 2 7Y' Town: Repair Permit M - © 3 TM # 1. Type of System: Conventional O Alternate O Comments: 2. Septic Tank Yes No N/A Comments a. Septic tank size —1,000 ... 1,250... other ..... cf n9 b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. Distribution Box i. All outlets at same elevation (water tested) ... ii. Protected below frost ......... . ................... iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box — bro erl set ............................ S a -Z` T l f. Trenches i. Systeni completely opened for inspection ii. Length required Length installed iii. Pie slope checked ... ............................... iv. Installed according to plan ..................... v. 10 & from property line — 20 ft — foundations ... vi. Size of gravel % - 1 '/2 " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... viii. Ends capped ............................. g. Pump or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per a roved plans b. Fill section — c. Distance from water course /wetlands 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box ......................... c. Backflll 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: RFSI Rev - 011312 John P. Nilsen 1 Bullet Hole Road Car nel, NY 10512 14 �,� V �_ % 119/1 AL e W-1.14 PVC Add For 17y 4'J o J --7 aoe,q Aark 5 Ve-nice IZA, (� ��p(' sm y► Ff QQ A -4x HAM +q CIO 14 p 0,$, ljo� o'k- a, .TT AM 0 R uj EL ir PPS 6 TI uj ul x SIN Nis Iwo V ........... U3 0-9 vis 0 IE 13 RD PJL NOSIGOW ER PL N PL Oki 0 1A • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: 7 l%enrg_ Located at (street): A5<38 ( ) TM # Section: Block Lot Municipality: i.ey/ Watershed: SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: a. Date of Percolation Test: ,2 Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop water level drop in inches Percolation Rate min /inch 2- 3 d - a-' 3 0 23 /y - a- / 4/0 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 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 min /inch, < 2 min for 31 -60 min/inch). All data to be submitted for review. il,.,( 3r, 5a4 low mk 3,s Ile,i fir, 5" &T '�ra4 << °Pey J z ��v