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BOX 10
00911
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00911
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
YES NO Internal Use Only R0 ^ 0
❑ VRepair epair Permit issued in last 5 years ❑ Ngt in Watershed
❑ e air within Bo d's Comers W. Branch or Croton Falls Res. ; —DDele ated
P Y 9 ❑ within 200 ft. of a watercourse or DEC-mapped webaand ❑ Joint Review
SITE LOCATION �(�� �,� �, ��„� l� t? Fy}S�rl�Cf/ TM #
OWNER'S NAME 40olz k �EDIL.4.cyMY-) PHONE #
MAILING ADDRESS 0 2 ,o tCtlj Y�i- i�2��7� A(-V
APPLICANT ('`jw&yc -n...
Q1 G► Name & Relationship (i.e., owner, tenant, c`ontractor�)f
DATE u /J 0 C FACILITY TYPE / S ell C f-- PCHD COMPLAINT #
PROPOSED INSTALLER jot ZY-, PHONE #. ft-- 079-6de'?
ADDRESS REGISTRATION /LICENSE # �)C VV-4
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 trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
I, as owner, or rep rted agent of owne �ree to the conditions stated on this form
SIGNATURE ���!C%ITLE DATE Ell
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
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
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phonZacrdance
3. System repair to be performe with the
above proposal and conditionProposal Approved posal Denied _
nspector's Signature &
Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner j!!2r7`g_a�i(/zz -z,1e7;� Address to / s o Zo.4gu
Located at (Street) Tax Map Block Lot
(indicate nearest cross street)
Municipality Watershed Cj,g_ 4
SOIL PERCOLATION TEST DATA
Date of Pre - soaking Date of Percolation Test
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R
2
3
4
5
1
2
3
4
5
NOTES: 1. Tests to be reheated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
DEPTH
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'
9.0'
__ .. - - -- _._.. -..
10.0'
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. HOLE NO.
-/101
"HOLE NO.
Indicate level at which groundwater is encountered A kAh
Indicate level at which mottling is observed A JQA4,_r-�
Indicate level to which water level rises after being encountered
Deep hole observations made by: �G I>,kf Date _B
Design Professional Name:
Address:
Signature:
Design Professional's Seal
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