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HomeMy WebLinkAbout0923DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.40 -1 -14 BOX 10 1 �I to ,;�I .` t� ,, r 6.r �� IN or 00923 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR Internal Use ❑ COY Repair Permit issued in last 5 years NQ ❑ Not in Watershed ❑ 2/ Repair Repair within Boyd's Comers, W. Branch or Croton Falls Res. � Delegated El 1/ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review �� ° SITE LOCATION ) j L) OWNER'S NAME PHONE # MAILING ADDRESS n -Z ).2 ' 4`3 APPLICANT a, Jo . TL r 7 %/er, Name & Relagnship (i.e., owner, tenant, contractor) DATE ® 9 —;2 ? -040 FACILITY TYPE h6ine_ PCHD COMPLAINT # PROPOSED INSTALLER. 4o-y PHONE # ADDRESS REGISTRATION /LICENSE # 04- d'31 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 engineer or registered architect. I, as owner, or rep rted agent of owner agree to the conditions stated / on this form SIGNATURE TITLE Pro osal a r ed with the followin conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owners 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 phone number 3. System repair to be performed in a rdance with the above proposal and conditions Pro sal Approved Proposal Denied d ll ector's Signature & Title d Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 DATE 0 Sheet » 'COUNTY of *. * E HEALTH r� �`ir _? ` _I2I�'ISION. tDI�' EY`l`V 11 YVTrY�1LTitV 1 A' -ATL=H SERVICES FWLb AMVITY REPORT NAMR: f'EM ..P Tel: . AnT)RFR�; l w L „j;.f,,�� AF - a Street F - Town State dip PERSON IN CHARGE = rI *!?s t' .-Name and Title TYPE OF FACILITY , loo , r5 S - FINDINGS. � e . { �+ .- Y �L . 5 b i • •_ ♦ .�,�,' - -, _^�'_�.i'�C.�`�^y ^C_ -..,` '.:'^..�'i, _..._ i ru R o'_- = 'JCL== �'- ^'�sJ'- C t t `- A� f .Si attire and Title TV I a knowledae receipt` of this report SIGNATURE: > _ " = 02/96 Title: - - Rev.--- t .r - s PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: -P JAW Address: 9AVQQ Il%`, Located at (street): '0n,✓t Section: X� lock Municipality: r lq IT E � 90 /I/ Watershed: SOIL PERCOLATION TEST DATA Lot /y Witnessed by: TDiGir j- PmAv"�-11 Date of Pre - soaking: C g Date of Percolation Test: b� Hot 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 1 –/ J 2 �° .z b 30 - �° 4 2 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. / 2. Depth measurements to be made from top of hole. 149 Ofd Form DD -97, pg 1 of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO_ HOLE NO HOLE NO HOLE NO HOLE NO G.L. © — 6 .r-5 0.5' 1.0' 1.5' 2.0' 2.5'� 3.0' 3.5' 4.0'i l� 4.5' 5.0' 5.5' f, w✓t l'^ 6.01 rC 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 Indicate level to which water level rises after being encountered Deep hole observations made by: Design Professional Name: Address: Signature: Design Professional = Seat Date ° ' .... ... .... __�___ ZNJ 14-V - ` ~7 ` .'1� ou FRi m r .2-� -i f ............. Y- 7/3 -/O.q D7 CO ' �ml w gy R cu z OWNER'S NAME SITE L=TION A PU'1'NAM COUN'T'Y HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR PHONE TO MAILING ADDRESS PERSON INTERVIEWED -�,, ' PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of.same type as original sewage disposal system. Different location may require submittal of proposal from- licensed professional engineer or registered architect. Proposal approved Proposal Disapproved tions: Date 1. Procurement of any Town permit'i'`.f 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 canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot.+ gravel). e. Installer's name and number. 3. System repair"to be performed in. accordance with the above proposal and conditions. I, as owner, or reported agent of-owner agree to .the above conditions. SIGNATURE S A (T & TITLE . DATE J " , 1 175: WAte (PCID); YeUrow 0ban BI); Pink (Appliaent) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL IlNDNUDAL ADDITION/REPAIR FORM SECTION A: GENERAL I`ivTFORI ATION Name of Project C 6 77°-' �)(v) & -76 u a TM# ,2,F. `- o 5' Year of Construction /7S Size of Parcel - 0'D A l O D SECTION`B. TOPOGRAPHY (Please check all appropriate boxes) 1. ❑Hilly ❑Rolling ❑Steep Slope Gentle Slope ❑Flat 2. ❑Evidence of wetland Clow area subject to flooding ❑Bodies of water Rrainage ditches Clock outcrop . NO 3. Property lines evident? 4. Water courses exist on, or adjacent to parcel: ❑ 5. Existing individual wells within 200ft of the existing SSTS? ® ❑ SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. ❑Level e0eGentle Slope ❑Steep slope B. ❑ Well drained Moderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) ®Extremely limited [)Somewhat limited ❑Adequate ft x ft D. INSPECTION Date `2 / Inspector y "� Pcfz _ L. ONo evidence of failure lEvidence of failure ®Evidence of seasonal failure I=---------=------- - - - - -- ---------------------------=----------=----==--------------------- L I fi (Indicate North) St-47* RED /7/a 2 T- OfVotG 14 A IN Z°' PO.OL F OUsr ----------------------------------------------------------------------------------7------------- 3Q Zbq A) �D (1) Indicate location of SSTS A. Size and type of septic tank gallons 531metal Concrete OPlastic B. Type of absorption area 1. Fields �t ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING WATER SUPPLY 13PWS MShared well ®Individual well ���.° w G R4 A 67' IlDrilled C]Dua' ®Casing above ground CONISENTS : AaPek-rZ /Do t, 'Pi C.- A).-t /) D I REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: SCALE IN 1110 OF AN INCH 1 1- 800 =345 -7334 1 -- - --� . N X600 —° � mt � 'P %0 25.32—.1.2/ / Xw wI 0 .99.63 L / \ \ ' 12 •� \ \ JITY/ Jr3G � _ ,L7UIf J6[K / 25 .43 / (Y C R G L �•SJ ` I6Yy N/O i / / rf // _ / C/i/ V C ;Jed 8 I r 1 jai faJB I So r r 1a 1 / 1 ' 4p p0 I 1 1 re / J 1 ORDAN e0.00 r 1! J9J0 1• _ + _ I NNI O fpQco 11 - _ Ifb.OZ fo000 JArI • f0ao0 _ Jsvi fop 00 ` .Wf � I I ON I V.0 1 A`X r r r I a I 1 ? f ! 4O.Op o 6q co `v � � u Op - jdw l r I r 1 28 I ! 27 /40. r ` a r I. 30 _ $ _ _ iut/ .rue! I . r r / � r /I r 126 ' NY 6400 Wfv NO / f040p Jitr Itf 40.00 Nd l Jed/ 60.00 ii /I l �. (!66/ 1 Nee ` `NN J6I! / J6I6 _ g 1 1 1 � Nel NNliesr J f4gpp /000 .AfNr ArMl I Mal I 32( KENDAL r 1 r l l I r r fpf.J6 !40.00 1 r 3 — / 'b•o 1 AW 43 _ ' isxr l r 1 I 4Q 00 "PERK F,rT „ Ho, v H � r- DELIS '� ft9sric. _7°RIJ11 l' DEEP