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631- 589 -8100
25.48 -2 -4
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ! S�
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR j
YES Intern'
nternal Use 0--nly PERMIT #
Repair Permit issued in last 5 years U Not in Watershed 1
Repair within Boyd's Comers, W. Branch or Croton Falls Res. 1) a +r. ❑ Delegated
❑ Repair within Zoo ft. of a watercourse or DEC - mapped wetland W Joint Review
SITE LOCATION I J / TOW # a5. Q/.
OWNER'S NAME � � �� / ,��.- PHONE *# 010 V
MAILING ADDRESS
APPLICANT
Name & Relatl hip (i.e., owner, ant, contr
DATE FACILITY TYPE iZ PCHD COMPLAINT #
PROPOSED INSTALLER' PHONE # r?
ADDRESS s "EGISTRATION /LICENSE #I
Proposal (Include a separate sketch locating the house, property lines, all adjacent wells within
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 of d extent of the repair. I
I, as owner,agree to t o ons stated on thi form J
SIGNAT �*- TITLE 2?rJ -�.• DATE 11Z9
(owner)
I, the septic installer, agree to comply with.the conditions of this permit for the septic system repair
SIGNATL`R£'" TITLE DATE -
pnstaller)
1. Procurement of any Towr Krrttlt, 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 DepartmenL
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
5 3l _ 3
Ins ector's Signature & Title Date/ ExpiratioffDate
,Repair proposal is in compliance with applicable codes Yes I/ No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
r
Mc Aleer
June 2016 110 Lakeshore Dr
Patterson
FOY
T
12'
1
26'
2
28'
3
29'
4
48'
5
48'
6
17'
7
15'
-8
49'
10.1
T
28'
1
29'
2
40
3
42'_
4
53'
5
56'
6
32'
7
39'
8
56'
11"A
Concrete patio
JEXCAVATIMG COMETH A r-Vn IN S
(845) 2-i9-8809
TR
'MIA
750 gal /2
compartment
poly septic tank
Concrete
junction boxes
19
36"x 9" 1p
M
infitrators w/
gravel
Concrete patio
JEXCAVATIMG COMETH A r-Vn IN S
(845) 2-i9-8809
Putnam County Department of Health - Division of Environmental Health Services
SSTS Repair - Final Site Inspection
Date: 61611(, Inspected by: G , Installer:
Street Location: //O Ga/z,-- Sko re 't>C Owner: 7-7e--A I e -c-
Town: 76, *e,rsvH Repair Permit #: R - o is q -/6 TM # .2 S . 4,Q
- - ---- ._.._......._._.. -. -- - -- - - - - -- -- _.. -
1. Was System inspected? Yes Er No 0 If not, explain:
2. Type of System: Conventional Alternate 0 Comments:
3. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size -1,000 ... 1,250... other ..... 76-0
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.Ina�e�Q -DeSig h C.Ls 540wN
o v` M5 - bvl/�-
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
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
YNDALL
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PrIc SYSTENSIve
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EXCAVATING CONTRACTORS
20 Ivy Hill Rd., Brewster, NY 10509 (845) 279-8809
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Environmental
Protection New York City Department of Environmental
Protection
SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR
DETERMINATION
Pursuant to the authority granted under:
Article 11 of the New York State Public Health Law; Rules and Regulations For The
Protection From Contamination, Degradation'and Pollution Of The New York City Water
Supply and Its Sources, ,15 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR
Appendix 75 -A Wastewater Treatment Standards- Individual Household Systems;
Putnam County Septic Repair Program Plan — March 2005.
DEP. Project# TIM PCHD Rep air# .
Site Location: l�y ��er -7/ T.M.# o? ,7- 2.,.q
Reason for Joint Review: /
Drainage Basin.. 200' of WC/Wetiand !/ Repeat Repair in 5 Yrs.
Name of Owner:
Owner's Address:
Drainage Basin of Project Site: y 0'?�5kc
Installer• 6��ef� .irt Sy ✓.,�,,h -r _ ._ .. .. .
General Description of Sewage System Repair: J�. � �� 11 'typ. b y� �� ���-✓
�lvvttl.�; itif!l7l� v f A�pc�d►�•; .4�er� CY'(*.r
V
hev
eL
Dates of Site Inspections and Soils. Tests: old Tl 6
T
Approved t/ . *Incomplete Delegated "Denied..
*Required: Soils Tests - Repair Sketch. WC/Wetlands Wells Other
* *Reason '
Det 'nation made by:
Engineering Division Date.
r�
! %Quick4 Plus Standard Low Profile Chamber
8„
34"
Quick4 Plus All -in -One 8 Endcap
8"
3.3"
INVERT
Quick4 Plus All -in -One Periscope
■lam/
UN-I F LTRAT®R®
s 5' ✓ms 111 C,
" I
10.4"
EFFECTIVE
LENGTH`
When installed
between
2 chambers.
13.3"
EFFECTIVE
LENGTH`
When installed
at the end
of a trench.
NIPPON!
4 Business Park Road
P.O. Box 768
Old Saybrook, CT 06475
860 -577 -7000 - Fax 860- 577 -7001
1-600- 221 -4436
www.infiltratorsystems.com
Quick4 Plus Endcap
4.5"
EFFECTIVE
1 r. LENGTH`
3.3"
INVERT
-a
INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY
6"
(a) The structural integrity of each chamber, endcap and other accessory manufactured by
Infiltrator ( "Units'), when installed and operated in a leachfield of an onsite septic system in
accordance with Infiltrator's instructions, is warranted to the original purchaser ( "Holder") against
defective materials and workmanship for one year from the date that the septic permit is issued for
the septic system containing the Units; provided, however, that if a septic permit is not required by
applicable law, the warranty period will begin upon the date that installation of the septic system
commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate
Headquarters in Old Saybrook, Connecticut within fifteen (15) days of the alleged defect. Infiltrator
will supply replacement Units for Units determined by Infiltrator to be covered by this Limited
Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation
of the Units.
(b) THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE.
- THERE, ARE NO 0•THER'WARRANTIES WITH RESPEGT T&THEd1NIT3 INCLUDING NO
IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE
(c) This Limited Warranty shall be void if any part of the chamber system is manufactured by
anyone other than Infiltrator. The Limited Warranty does not extend to incidental, consequential,
special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages,
including loss of production and profits, labor and materials, overhead costs, or other losses or
expenses incurred by the Holder or any third party. Specifically excluded from limited Warranty
coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse,
abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which
are not permitted by the installation instructions; failure to maintain the minimum ground covers
set forth in the installation instructions; the placement of improper materials into the system
containing the Units; failure of the Units or the septic system due to improper siting or improper
sizing, excessive water usage, improper grease disposal, or improper operation; or any other
event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply
with all of the terms set forth in this Limited Warranty. Further, in no event shall Infiltrator be
responsible for any loss or damage to the Holder, the Units, or any third party resulting from
installation or shipment, or from any product liability claims of Holder or any third party. For this
Limited Warranty to apply, the Units must be installed in accordance with all site conditions
required by state and local codes; all other applicable laws; and Infiltrator's installation instructions.
(d) No representative of Infiltrator has the authority to change or extend this Limited Warranty.
No warranty applies to any party other than the original Holder.
The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of
states and counties have different warranty requirements. Any purchaser of Units should contact
Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to
obtain a copy of the applicable warranty, and should carefully read that warranty prior to the
purchase of Units.
U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending.
Infiltrator, Equalizer, Quick4, and Side Winder are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc, is a registered trademark in Mexico.
Contour, Microl-eaching, PolyTuff, ChamberSpacer, MultiPort, PosiLock, QulckCut, QuickPlay, SnapLock and StraightLock are trademarks of Infiltrator Systems Inc.
PolyLok is a trademark of PolyLok, Inc. TUF -TITS is a registered trademark of TUF -TrTE, INC. Ultra -Rib is a trademark of IPEX Inc.
020131 nfiltrator Systems Inc. All rights reserved. Printed in U.S.A. PLUS01 0813
Michael J. Nesheiwat, M.D.
Interim Commissioner of Health
Robert Morris, P.E., MPH
Directof df Eff ironmental
Department of Health
1 Geneva Road, Brewster, New York 10509
(845) 808 -1390
MaryEllen Odell
County Executive
TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
nTTN: `CANNY 51��1� La
IoM:
t
DELEGATION STATUS
•a
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
JOINT ICEVIEW
LOCATION:_//0 .L ack�
TOWN: ,e�sof-9 TM # Z,6�, ;(g
NOTICE OF' COMPLETE APPLICATION: DATE: 61Z s l6
❑ Within the drainage basins of West Branch, Boyds Corner, or Croton Falls
eservoirs
W. Within 500 feet of a reservoir, reservoir stem or control lake.
❑ Within 200 feet of a watercourse or a DEC wetland and appearing on a
subdivision map approved after December 31, 1992
❑ Design flow greater than 1,000 gallons /day.
❑ Commercial SSTS.
SEPTIC REPAIR JOINT REVIEW
PUTNAIVI COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIROI?TMEN'I'AY. HEALTH SERVICES -
DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATNMNT SYSTEM
Owner: CA e—e -r- Address: t l CL L u- Ice- .'5
Located at (street): TM #
Municipality: PAA:Q'Sarl Watershed: 46L:�z rG4-i/l.�'�
SOIL. PERCOLATION TEST. DATA
.� Witnessed by:
Date of Pre - soaking: 5 Date of Percolation Test: '
Hole
No.
Dole
depth
(Inches)
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
2,6 — 2.3
3'
O
3
z 3 °!: O
2-02
3
-,%
5
2
3
4'
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
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE #__I HOLE # HOLE # HOLE # HOLE #
G.L.
0.5' 6"
2.0'.
2.5' s on>\
3.0'
4.0'
4.5'
5.0'
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 IaALz-
Indicate level at which mottling is. observed �'^ /(�C��► %
Indicate level to which water level rises after being enco tered
Deep hole observations made by: i Date— r;
Design Professional Name:
Address:
Signature:
Design Professional's Seal I
Revised July 2013