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BOX 11
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. PUTNAM COUNTY HEALTH DEPARTMENT A
DIVISION OF ENVIRONMENTAL HEALTH SERVICES /
_ {zl _ . _... __.._.__ _. PROPOSAL - FOP,SEWAGE TREATMENT SYSTEM - REPAIR -.
YES
Internal Use Only PERMIT #
V vV
Li )5l Repair Permit issued in last 5 years U Not in Watershed
❑. Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ 1 R„ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION., ;yz,_v I,, TOWN �'grsnn TM # g
OWNER'S NAME. OQ,/ Ftrt ll PHONE #
MAILING ADDRESS S9n�
APPLICANT J rime -S &AAr,
Name & ReQonship p.e., owner, tenant, contractor)
DATE FACILITY TYPEme'. PCHD COMPLAINT # S v
PROPOSED INSTALLER —gInes lT //;Vv PHONE # 9/Y' ` -_1- _A ;"71
ADDRESS 137 45 66? + R�- ��,, ,,,,Y REGISTRATION /LICENSE # PC-Bl iaze
Pr 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.
. ws4-L1( LOGO resod. L�VG %4v� l+f au�.. two 330 JZeclnQ�na:r
W/ LI a1'1-QVe_ i,A _4SQwI.L�. �o Ga 'Emvt GLS ,Ai1`in nun 1 e._�,J__ .....
I, as owner,agree to the conditions stated on this form
SIGNATURE (,,>�lI TITLE DATE
(owner
_.,:_...:...._
I,. the. septicinstaller, agree to. comply with. the. condiVons.of -this. permit for tlhe'"eptidsystemrepair-
SIGNATURE *o TITLE J�X lhr. DATE iJS = _,)1a/ ,y
Promw the following conditions:
(Installer) y' .
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.
IMTERNAI IICC nNl V
Proposal Approved Proposal Denied ❑
Inspectors Signature & Title Datd ExftirationDate
-Repair proposal is in compliance with applicable. codes Yes ❑ No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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Putoam County Dgpartment of Health
Division of Environmegtal $ea1t6.Services .
SSTS Iltepalr - F! ai •Site Inapee on
Date: !o (L� Inspecoed.by Installer: 1 &rdo
r
Street Location: ;&67 r r e-/
erP
Town:~ I�ci, #adz Repair ermit 0. -?L 0 7! ;j TMi # a.s ;
1. Type of System: Conventional 0 Alternate O Comments:
Additional Comments:
RFSI Rev - 011312
No
N/A
' Comments
a. Septic tank sin ,000 .. 1,250... other .....
b. Septic tank installed level ......................
Ed.Yes
c. 10` minimum from foundation ..................
DistribitinNex
n1®v'e
i. All outlets at same elevation (water tested)...
ii. ' Protected below frost .............................
iii. Minimum 2 ft. Original soil between box &
treachea
'
is
L S letely owned for Inspection
ii. Length required /!j_ Length Wtalledd_
'
(2) 330 C v
� C
iii. sl6pe checked ... ...............................
iv. Installed according to "plan .....................
v. 10 ft.' from property line - 20 ft - foundations ...
Sa w� era ew
Ale,
vi. Size of gravel % - l 'h " diameter clean .........
vii. Depth Qf gravel in trench 12" minimum ........
viii. Ends
ago Rg R" ftto=
3. t"rjjjl:j!j:jjiljjjijjjj.� Am
a. SETS Area Roded as per approlved Plans
b. Fill-section-
c. Disaaco Am water tour Wwetlaads
4. Overall WorkmandLIP
"
a. Boxes properly grouted and installed correctly ...........
b. AU pipes flush with inside of box .........................
c. Backflll material contains stones <4" diameter .........
d., Curtain drain & standpipes installed according to plan
1
4
e. Curtain drain out&H protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
RFSI Rev - 011312
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2 330
. Notek
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each min for 1-30 minrmch,:5 2 min f6r 3 1.60 min/inch). < r
All " to,
2. Depiih'-me-wimiments to be made from top of hole.
Form DD-97, pg 1 of 2
Deoth to
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waggir NOM
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IM
I
. Notek
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each min for 1-30 minrmch,:5 2 min f6r 3 1.60 min/inch). < r
All " to,
2. Depiih'-me-wimiments to be made from top of hole.
Form DD-97, pg 1 of 2
::TEST PIT DATA
DESCRIPTION OYSOII"S'F TCOUNTERED N TEST HOLES
Design Professloaal's Seal
Revised July 2013