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631- 589 -8100
25.47 -1 -64
BOX 10
01016
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PUTNAM COUNTY HEALTH DEPARTMENT i
DIVISION OF ENVIRONMENTAL HEALTH SERVICES i_r-- S r
ADAQAl IMAD CCWAIC TDCAVRACWT OVQTCU 0CDA110 0 ��
O Internal use Only PERMIT # ( ='u4 J- Lt 'p
11 epair Permit issued in last 5 years ❑ 4ot in Watershed
❑ 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 RA_ TOWN TM # aS.41- i
OWNER'S NAME (e �r�t?F, I=9� f.� E�_�;•� -- L.c�ry;1 PHONE # %-J5 -`j, QD&
MAILING ADDRESS
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
I
PROPOSED INSTALLER L Irl I n 3 C- WV PHONE # 53 C ; -`, ,R(g- -Q`�-
�i' I
ADDRESS �SyC� REGISTRATION /LICENSE # bi o1 1�
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
I, as owner,agree to the coryfiitions stated on this farm
SIGNATURE TITLE V(o7nr DATE
(owner)
I, the septic installer, agree to comply th conditions of this permit for the septic system repair
SIGNATUR TITLE DATE 7�j
pnstaller)
Proposal ooroved with the following ponditions:
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 backfi &until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal rov d - Proposal Denied El
Inspe lgnature & ale Date Ex ration to
ReDair oronosal is in comDliance with aDplicable codes Yes No 0
COPIES: PCH D; Owner; Installer s
PC -RP 99ML Rev. 2107
Putnam County Department of Health - Division of Environmental Health Services
SSTS Repair - Final Site �In_sp�ec tion
Date: � 16 Inspected by: tom, Installer: Tm1skma z xe'
Street Lo ation: �.� _ 5 - . �e -c tCd(, Owner: —Oe :So i ll+ - fro v�
Town: 1 em Repair Permit #: -K - p % - /6_TM # ZS , S'7
1. Was System inspected? Yes 0 No ❑ If not, explain:
2. Type of System: Conventional 0 Alternate 0 Comments:
3. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size -1,000 ... 1,250... other.
b. Septic tank installed level ......................
4. Distribution Box
a. All outlets at same elevation (water tested) ...
'
5. Junction Box - properly set ...........................
6. Trenches
a. System completely opened for inspection
b. Length required Length installed .
c. Pipe slope checked ... ...............................
d. Installed according to plan ......................
e. Size of gravel % - '1 '/2 " diameter clean .........
f. Depth of gravel in trench 12" minimum .........
g. Ends capped .... ...............................
7. Pump or Dosed Systems
8. Sewage System Area
a. SSTS Area located as per approved plans
b. Fill section -
c. Distance from water course /wetlands
9.. Overall Workmanship
a. Boxes properly grouted and installed correctly ...........
b. Backfill material contains stones <4" diameter .........
c. Curtain drain & standpipes installed according to plan
d. Curtain drain outfall protected & dir to exist watercourse
_.
e. Erosion control provided ............................
COPIES: PCHD; Owner; Installer RFSI Rev - 011916
N v3.
Septic uift Information:
Homeowner:
Charles & Estela DeSaint -Leon
72 Slater Road
Patterson, NY 12563
Town of Patterson
Tax Map: 25.47 -1 -64
Installer:
Philip Leonforte (License #1022)
Precision Excavating Inc.
3 Rochambeau Road
Garrison, NY 10524
Description of Repair to System:
Installation of 25' of ARC18 Chambers
3' Trench With 1 ' /4" Washed Stone
Installation Complete: 5 -27 -16
Scale: Not to Scale
Legend:
B -1 =9'
A -2 =43.5' B -2 =28'
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ZP.DN ROD
Owner: Address:
Located at (street): TM # 2. of 7
Municipality: Watershed: �6ZS4— -5f'c�+���
SOIL, PERCOLATION 'TEST. DATA
Witnessed by: c _
Date of Pre-soaking: J , S
Hole
No.
Hole
depth
(Inches)
Run
No.
Time
Start — Stop
Elapse
Time
(min.)
Depth to
water from
ground
surface .
surface.,
Start - Stop
Wager
level drop
in ibches
Percolation
Rate
min/inch
3.2"
1
30
i� �a-
30
2
— (ff�-7'�F
2z-
3 0
)LS' x- 26
` z
5
1
f_
2
3
4'
5
f.
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 mL 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
T'ES'L' PIT DATA
IDESCRLPTION OF SOLLS ENCOUNTERED IN TEST DOLES
DEPTH HOLE #__L_ .HOLE # HOLE Al HOLE # H ®LE #
G.L.
0.5' �� S
1.5'
2.0'.
2.5' SQ�l
3.0'
3.5'
4.0'
4.5' o..
5.0' G1G-
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5.'
9.0'
10.0'
Indicate level at which groundwater is encountered ^Oo U
Indicate level at which mottling is. observed
Indicate level to which water level rises after being encountered
Deep hole observations made by:, iL Date
Design Professional Name:
Address:
Signature:
Design Professional's Seal
Revised July 2013
BRUCE R. FOLEY
Pwbfie
LORMTA M%M4M , - ,
__ t " __jW_X, _..
Associate Public Health ftwdor
Dftaor of Patient Sw.*= .
-DEPARTMENT OF HEALTH
I Gama Road - - .
-Brewster, New York 10509
R�FOtJEST FOR ---FIELD TESTING=.
ATTENTION: 13 JOSEPH PARAVATT C1 GENE REEL)
All information below must be bb completed prior to any scheduling. DATE.-
ENGINEER ORFIRM: PHONE #; !RqS-13 L-:.Q%'11
REASON:
ROADISTREET:
TOWN:
SUBDIVISION:
DEEPS: )( - PERCS: ❑ PUMP TEST: ❑
TAX MAP#-. 'X. -AJ -1- (jog
LOT#-.
OWNER:
Oil
P1,
NYCDEP
CRITERIA
FOR JOINT
REMW AND WITNESSING
OF SOIL _TF3TlNQ
YES NO
❑ ❑ Proposed SSTSwithin the drainage basin ofWatBranchorBoyde Corner Reservoirs.
13 _E3_. P
roposed-SM widda 500 feet of a reservoir, reservoir stem or control take-
-pnoo-M SM,wiffiii-m feed iniii6i;iBrie,or a DEC wetland.
Proposed MIS design flow greater than 1000 gaRonsiday or SPDKS Permit required.
❑ ❑ Proposed SM for a C;omm=vW Project.
It Is the responsibility ofthe design professional to provide the above information prior to soil testing.
This Department wftl determine the NYCDEP project states (Joint or Delegated) based on the
response- H you answered jM to any of the questions, NYCDEP must witness the sell soft This
Department will coordinate a mutually suitable time for field testing with the Design Professional and
NYCDEP.
U a project has been determined to be Delegated basid. an the above response and then subsequent
information indicates NYCDEP ft required to witness the soil tests, it will be the sole responsibility of
the design professional to schedule re- witnessing of the soil bed" with NYCDEP.
FOR COMM USE ONLY
DATE. TRAL.
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Putnam County Department of Health - Division of Environmental Health Services
SSTS Repair — Final Site Inspe tion
Date' �. /� n Inspected by: Imo. Installer:��r_is,� rC,
Street Lo ation:� —� I�r , Owner:
Town: ��aec5o:n Repair Permit #: TM # �.� , 7
1. Was System inspected? Yes 0 No 0 If not, explain:
2. Type of System: Conventional 0 Alternate 0 Comments:
3. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size -1,000 ... 1,250 ... other .....
U �e '-X i5{; Hc�
b. Septic tank installed level ......................
j
4. Distribution Box
i
a. All outlets at same elevation (water tested) ...
5. Junction Box — properly set ...........................
6. Trenches
a. System completely opened for inspection
b. Length required Length installed
C. Pipe slope checked ... ...............................
d. Installed according to plan .....................
e. Size of gravel % - 1 '/Z " diameter clean .........
- f-_._. ]Depth of gravel in trench 12 "- minimum
g. Ends capped .... ...............................
7. Pump or Dosed Systems
8. Sewage System Area
a. SSTS Area located as per approved plans
b. Fill section —
c. Distance from water course /wetlands
9. Overall Workmanship
E
a..' Boxes properly grouted and installed correctly ...........
b. . Backfill material contains stones <4" diameter .........
c. Curtain drain & standpipes installed according to plan
d Curtain drain outfall protected & dir to exist watercourse
1
e. Erosion control provided ............................
`
COPIES: PCHD; Owner; Installer RFSI Rev - 011916