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Home My WebLink About1003DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.47 -1 -27 BOX 10 JA ��. 01003 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL- MR- SEIt"GE-TREATMENT SYSTEM- REPA6R- -. YEJ N Internal Use Only PERMIT # (r _� -" - `Z ❑ / Repair Permit issued in last 5 years Oot in Watershed ❑ ,L�`I/ Repair within Boyd's Comers, W. Branch or Croton Falls Res. &I Delegated ❑ Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review SITE LOCATION � , ' j ` I Z Z C OWNER'S NAME PHONE # ! — Ifi i z, MAILING ADDRESS jG* ,,LI 6 APPLICANT +�-J5_ r Al i4 P- 0 �' ir_ . ,LI B "'— CC ,� C �24z Tip' -6k %L` Name & Relationship (i.e., owner, tenant, contractor) 1 DATE Q .2- (- Z FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER' iY l�'� %G'6 -% G�ltj!`�i(C'fl vGi )4(e; PHONE # ADDRESS flj i 4 REGISTRATION /LICENSE # 4 Pro sal (include a separate sketch locating the house, property lines, all adjacent wells within 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 extent of the repair. LL T I, as owner,agree,Qthe conditions Cited on this form SIGNATURE ;A � � �- 2..� -� . �s� TITLE 4 DATE �- (owner)f' I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE ✓� -� vL �=� 'L'L "\ TITLE �f�� DATE ('�� /G /Z (Installer) Proposal an[xoved 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 3o 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. WTCOUM O ICC e%W1 V Proposal Approved , .r Proposal Denied ❑ Inspectgr -Signature & Title Date s Expiratio Date ,Repair proposal is in compliance with _app licable codes__ Yes COY No ❑ COPIES: PCHD; Owner; Installer PC- RP,99ML Rev. 2/07 �R as. �'Y�wl -., .ej r .q.�,.+�w �- � ,:rmrxx�en�, �� r +-z�:< <,�. -�� 4•��"' °: . M � r>M� r.. •n.� M�t�� ay.. .n:x _� r _ rY' d F �« ov � All low JO -s,V-0".I 'Fpon DeKl( p/. 40" ��M 9,9 RAI o Lt �C/ D 30 /3 k, 3 f3+ 21 ii Ll r :, kiN Z no CO Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Final Site Inspection t Date' �/ /Y /�Z _ Inspected by: C e t � e- k r � Installer C&' / � L%► Yt`� Street L- o�ation: -._ - Owner•. - - - - Town: f�� -r�-� Repair Permit # 0 — J -2-- TM # o;,, ,� V_ __.� ...__.�..._. g, aypc va oya An. OiVnvcn uUna l LJ floc! HALO LJ 4.Qnl(MUNH5: Z. Septic Tank Yes No N/A Comments a. Septic tank size -1,000 ... 1,250... other ..... 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 -properly set ............................ f. Trenches !/ i. System completely opened for inspection ii. Length required Length installed / l� iii. Pie slope checked ....................... :.......... iv. Installed according to plan ..................... v. 10 ft. from property line - 20 ft - foundations ... / vi. Size of gravel % -1 '/Z " 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 approved plans b. Fill section - c. Distance from water course /wetlands C/ 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box ......................... c. Backfill material contains stones <4" diameter ......... v d. Curtain drain & standpipes installed according to plan e. Curtain drain outfall protected & dir to exist watercourse J f. Footing drains discharge away from SSTS area ......... g. Erosion control provided ............................ i - Additional Comments: s lil "/, 11/ _ RFSI Rev - 011312 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES THIS IS NOT A REPAIR PERMIT PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All information below must be fully completed prior to any scheduling SITE LOCATION C(% � l r�'r�t� . &TOWN.F4A1Ad /%I, TM #,,- , � 6 �r OWNER'S NAME �5. -�' L�f _ PHONE # - 2-751 --11136 MAILING ADDRESS j4 L9 <t J PROPOSED CONTRACTOR /INSTALLER C.. �L!��l�` PHONE ADDRESS `r� "`�' REGISTRATION /LICENSE Reason for exploration: failure to surface ❑ back -up in house ❑ find limits of system for repair ❑ other (explain below) kly:excel :septic .F ,- �4 3 Al IN "IN PUTNA�NI COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATfvIENT SYSTEM Owner: kJoA0\. Located at (street): Municipality: Address: TIN14 Section. -X., / Lat F Watershed: La.d SOIL PERCOLATION TEST DATA j Witnessed by: �� i � c Date of Pre - soaking: 2-1,20112- Date of Percolation Test: 2 .f, ;, Kole No. Run No. Time Start — Stop Elapse Time (thin.) Depth to water from Found surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch �iz4) 1 70 .2- — ✓ I -V- I 3 f) s i I f 2 3 I 4 I I - I 2 I 3 I E I � I 5 I ! ' I 2 3 4 s I f Notes: t. Tests to be repeared at same depth until approximately equal percolation rates are obtained at each percolation rest hale. (i.e., <I rain for 1 -36 min/inch. <2 min for 31 -60 min/inch). All data to be submitted for review. 2. Depth measurements to be made from top ofhote. Form DD -9i, pe f of'- i P TNA� COUNTY DEPARTMENT OF HEALTH. DIVISION OF ENVIRONMENfA:L HEALTH SERVICES INITIAL M. IVIDUALICOM MRCIA•L SITE INSPECTION FO SECTION A. GENERAL INFORMATION Name of Project M(V} n�'7 County, l - Site Locatiori.-A. Ise -A . Building construction begun ,Extent Is property within NYC 'Watershed? ................. 0 Yes ` 0 No SECTION B. TOPOGRAPHY (Please check aH appropriate boxes) 1. Q 'dilly- . -Q�olling' Steep slope Q�entle slope U Flat 2. Evidence of wetlands a Low area subj -t t to flooding Bodies.of water. Drainage ditches r7 I Rock outcrops 3. Property lines or corners evident...... ....... ....................................... 'des No 4.. 'Do water courses exist on or adjoin-the-pro perty? :....................:....:. Yes No 5. Will these affect the design of the sewage system facilities ?............ Yes No 6. Do watershed regulations apply in this development ? .. ................ ....... =Yes No .7. Will extensive grading be necessary?.......,.....:... ...... ...... .....:. ...........:.. Yes No 9'. WM extensive fill-be necessary.for SS` L. S? : SECTIOND. DRAINAGE- 18. Will proposed grading materially alter the nafurai drainage in this 'or adj acerrt areas? Yes No 1'9. Will groundwater or surface drainage require special consideration? ...................... Yes No ' 20.• Will gullies, ditches, etc:, be filled and watercourses be relocated ? .................. ..... Yeso SECTION E. REMARKS. 21. If a common water supply is proposed; has an-inspection been made of the existing or proposed source and facilities? ..:.....:.............:......... ........................,...... Yes: '• o impectiot data 22. Do adjacent wells and/or sewage systems exist? ................... ....:...:.:.:: ............ ...... Yes _NQ . 23. Additional comments 24. Site observerAnspector and title 25. Date(s).-of .abservaiion(s)inspecti-on(s) TEST PIT PROFILES - .Hole r � l Lot Hole 'Lot # Hole Lot r Depth to water Depth to water Depth tawater - ' _ .. _ .._... _. Depth to motting Depth.to mottling Depth to mottling Depth to.rocklimp. - Depth to• rockrimp. ' Depth to rockhmp. G.L. o sa ` I G.L. G.L.. as 0.s as 1.0 �. e � l � c � ��rl�n ..1.0 .1.0 2.0 1bctr, . �-�� o %J. 2.0 2•.0 3.0 3.0 3.0 4.0 -S6r.14 /ao, 4.0 4.0 5.0 c:w 7 g 0-a ri l ' 5.0 5.0 .6.0 6.0 6.0 7. 7.0 7.0 .8.0 8.0 8.0 9.0 9.0. 9.0 Mo 10.0 10.0