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HomeMy WebLinkAbout1007DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.47 -1 -32 BOX 10 I � L ,I T sr I Le r I a 01007 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ------ .PROPOSAL -FOR- SEWAGE TREATMENT-SYSTEM REPAIR- Internal Use PERMIT #1 U U Repair Permit issued in last 5 years U /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 !{ �' SQn �Wll TOWN P,, � "0✓1 TM # 2-; , ,� 7 - % — 32- OWNER'S NAME RV, �i1 S C-114 /'" PHONE # MAILING ADDRESS APPLICANT .��►7e s G4 >j Name & Relations (i.e., owner, tenant, contractor) DATE FACILITY TY�P -E- r" 9- PCHD COMPLAINT # PROPOSED INSTALLER __--- PHONE # ADDRESS 3 7 �if C, i�✓��yr REGISTRATION /LICENSE #�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 system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. ce 4 C 4� 3 ® 6 g,'71- Q Q1 i✓'l. � 1' a � ` f tiSx o ld vK sJc. o I, as owner,agrp4o the conditions stated on his form 'y SIGNATURE TITLE DATE' (owner) d 1 1, the septic installe to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE Y�llcA DATE pnstaller) r 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. 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. INTERNAL USE ONLY Proposal Approved is in Proposal Denied with applicable codes Date( Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 45-p e: ►i n i eG�l (cc. Wei/ 2- t3e-.I�mwa z- e-sitl e- w c.e- �cwe? ��-w��551on � •���kf -�ls apt �lZ3l`/ C�- ow� Pe�twV� n�ct,cao�aw�.�� 1�_ ��I S AA3(r,)`1z K( Ox,6.4-1 -Aj i-ox pt p se-,-Pa3e- t p c- �i oo c�L) 4V;;P, �.{� %ela W1� ;� "5ve. - 3:5- ?Ipe- I P UTN.,-A-M C 0 ULN-TY D E P ARTNIE INT OF HEALTH DIVISION OF ENIVIRON-NIENTAL HEALTH SERVICES DESION-D.-AITA SKEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: 02 ;7-6; �7 - / --3 Located at (street): TMil" Section: — Block— Lot ---- Municipa(iry: Watershed: SOIL PERCOLATION, TEST DATA Witnessed by: Date ofPre-soakinry- ZI Date of Percolation Test: ;2- z Hole No. Run '?14"o. I i Time Elapse Start- T , ime .Stop (min.) Depth to w r er from m ground r- surface (inches) S-fa iff S to 0 NVater level drop in inches Percolation Rate minlinch 3- -S 2 I 0a -/4 ",4 141 .3 :4 2 3 4 -5 .2 3 4 3 .4 Noces: TEST PIT DATA DESCRIPTION' OF SOILS ENCOUNTERED IN TEST HOLES HOLE t HOLE HOLE 5' AW Rr 2. 7 4I . Z. 3 .5 4 "j- 4. 5' n. E..,'. 7.0' 7 52 9.o. 4. _ 10.01 Lndkatelevel at Which pou.-dwater' is encount--7,-� Indicate Level at which mottling: is observed ©�� Level to wnlch water, Level rises ar,^L-.-. beiric-, -,_Jcounrere' i Deep hole obse-7 ations made by: Da,.!-, Desia-71 Professional .duress: ress: c � b 1 t N , ............ - I� _ w, ip ji 1 � PARTRIDGE LA IF C 2 • s 2 Fey i YATES =r O 99� 2 H JO N oq 1� �$ XENIA IC NP KENDA O yF C 110 Z a PE HAINE 2 \o ¢ YOUNG ao y G IN RD O DENm D / o z O I G R SW`s N IAO /: 8 Z W INA D O Littler "° -�� � CHES �. P, � NILES E � ''F' >``f`` G•9 D �2 co ROMEs D u< p RED Pond Q` <t p x �o R G c Z D � rT c FRE O BIW. RD ¢ y D Z TER C W iQ Nir J'` A OR ypLUTIOWN LA IR Tqr E 01 �f #i ": ;'.: ><' ?'i:E•,'::i;I;: OO V; cH ZUR ir 9 6 7 P P Q Q O 4� V S R O R q P F J O � n P W 9 5 Y Q� v P �Q� G i O H -3 P AZE DR � N 0 W P o N a 9 s Z A Z r: i A � F � N Q s 2 m m t P 9 G y O 1 Q Z V W � O r v a �a 9 4 r Z 9 i£> IAA N O NSO ��ra 1 .� N 9 v L R N 2 LI O 1 fr 9 D 'L O r 9 N 7A B A is Q � is ® m a El ier .. O W /ate; .: w v'aa<. ' <a •t �'t`x: r Q ```�•�� 66 � s� qn V D RIVER 4w2 t� O P R Z O p y a o RENDA b m 9 ® �0O ' � -10 2 ' � O (090 NMI QO �t AgBU i � 90 - i" LA r r 65 Sy D ova i✓ �v ti� JO a o 9 Corner 0 Pond b a ' 13