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PUTNAM'COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
YES NO Internal Use Only
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION ,�S}r 7°►oL� G fly' TM # t c5. y� -1- 3g
OWNER'S NAME �� FF }�-y M PHONE
MAILING ADDRESS ken ®z l %�� ,er�e Y �� 5���3
APPLICANT J/ n, a�, % ller
Na & Relationship (i.e., owner, tenant, contractor)
DATE 0�,� -7 dd" FACILITY TYPE #ellne PCHD COMPLAINT #
PROPOSED INSTALLER JC4Inl u 4%/'4 PHONE # d'�I1-`
ADDRESS 3,7 4 *;Ae- l qrm Ad- rcl,: i, &0X REGISTRATION /LICENSE #
e7° %/5?
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. n
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I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE L TITLE _-C -A 37 I DATE
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Pro osal a Ilowinq conditions: . rap ose C � .BS SI 5'r' ir( S GuoS� + `tib@S fi�� 5 �►
1. Procurement of any Town Permit, if applicable. y. is no fee •H:Y-
Submission of as built repair sketch in duplicate showing: 5�� � ?� +b [91C,6.k,f i IRA. ;6(
a. Owner's name n d�bh.
b. Site Street Name, Town and Tax Map number I i i'1 �p h oof &D14 �i,�i pfb v c,
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 accordance with the
above proposal and conditions.
rInspector's-Signature saeApv e Proposal Denied
r "lam . - 5 0g
& Title Date
J'COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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36 PAGE 525
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j'T 3 LOT 3672 LOT 3673- LOT 3674 WALL
CONCRETE,
CONCRETE WALK
LK N
SMITH-
/1 1\2 ST Ry"/ LIBER 716- PACE 10.71
j / /FRAME, // "/
T 3675
&3 C-4
IEN CLOSED I
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Sheet of
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PUTNAM COUNTY DEPARTMENT OF HEALTH
A
DIVISION OF ENVIRONMENT-AL.-HE-A-T-L-H -S-E-RAq-C-E-S- -
FIELD ACTIVITY REPORT
NAhAF# P /14 W% Tel:
Street Town State Zip
PERSON IN CHARGE
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nP WTPR VMVJPn: 1r)ptp.
Name and Title
TYPE OF FACILI'
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INSPEA-LOR'
a Signature and Title
RF.PnRT IRF.CFTVP.T) IRY.'
1 acknowledge receipt of this report: SIGNATURE:
02/96 Title:
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner: Nr� Ci Address:
-?r7 14
Located at,(street):� ��� 2� Section: 0`S�Block r Lot 3a
Municipality: �°G T7;F)Q90A1 Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by: Q1Lrr'T �i���QV,r
Date of Pre - soaking: Z2 ,93 Date of Percolation Test:
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
1
V
-'5
2
3
l
4
2
4
1 - N
Y 3
7,.3- 24,
,
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.
Form DD -97, pg 1 of 2
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