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BOX 11
01053
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01053
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13 Fill"
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT k -,231-0S
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use Only
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
Repair within 200 ft. of a watercourse or DEC - mapped wetland
TOWN A
PERMIT#
U Not in Water
kd' Delegated
❑ Joint Review
PHONE #
=13
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE A/z/1 FA7CILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER �i 1//sx - Q!' ;y PHONE #
ADDRESS
REGISTRATION /LICENSE # C%
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.
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner) .
_..1,.tbe.septicjnstaller, agree. •.comply with th conditions of..this perm it:for.th&septic system repair—/_:........_.....
SIGNATURE —TITLE DATE G
(installer)
Proposal approved 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 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
kCcompl eted SSTS repair will function.
No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Approved
pector's
is in com
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Denied
applicable codes
41T�C) C-7
Date
Yes
s
0 No 0�_
Rev. 2/07
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
REQUEST FOR FIELD TESTING
All information must be ull completed prior to.dny scheduling. Date:
]Engineer or Firm:
Ye 6r c Phone #:
Person to Contact: 906 yd6/
❑ New Construction ,Repair Program ❑ Addition Program
Reason: DeepsPeres ❑ Pump Test
Road /Street: 30 &err,Ane
Town:
-Subdivision:
Owner:
❑ . Project not within NYC Watershed
Tax Map#:
r�ItOL!
NYCDEP - CRITERIA F.OR .IOINT REVIEW ANIB WITNESSING"OF SOIi, 'TESThiG.
YES NO .
❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls; ur Boyds Corner
reservoirs.
❑ Proposed SSTS' within 500 .feet of a reservoir, reservoir stem or control lake.
❑ Proposed SSTS within 200 feet of a watercourse or a. DEC wetland.
❑ Proposed SSTS design flow greater than 1000 gallons /day or.SPDES Permit required.
❑ Proposed SSTS for a Commercial Project. .
It. is the responsibility of -the Aesign. professional- to provide' the-.above information prior -to- soil; testing.
This Department will determine the NYCDEP project status (Joint or Delegated) based on the •response.
If you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will
coordinate a mutually suitable time for Held testing with the Design Professions and NYCDEP.
If a' project has' been determined to be Delegated 'based on the above response and then subsequent
information indicates NYCDEP is required to witness the soil tests; it will be the sole responsibility of the
design professional to schedule re-witnessing of the soil testing with NYCDEP.
FOR COUNTY UL-ONLY
DATE: �I�3/ 0 5 TINtE: 7 - 3-?
COMMENT
Req.for field test:kly . 4/16/2009
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PUTNAM COUNTY DEPARTMENT- OF HL-AiLTH.
DIVISION OF ENVIRONMENT_AL,HEALTH SERVICES
DESIGN DATA. SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner: Address:
Located at (street): ion
TM # Sect: Block ;L_L0t,,7,f
Municipaliti, P�' Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by:
Date,of Pre-soaking:. 9,6 3LT,,. Date.of Percolition Test:
c.
Hole No.
Time
Run No. Start —
Stop .
I Elapse
Time 1
(min.) . a
Depth to
water from
ground
surfs ce .1
(inches)
Start - Stop,
Water 'Percolation
'level drop"" Rate
in inches. min' . inch
/7
1
2 14, a - x1
-0
5.3
1
4
7, 3
5)
3
4
5
3
3
4
NOEes:
i. . Tests to be repeated at same deoth until acurommatel-V toual DMOlatior rates are
obtained a',each De7coladon zest hole. min for 1-3G miniinch. <2 mirfoi-
3.1-6(nin/inchi-
Ul data obesubmitted fo-revie W.
Death measurements to be made. from tar.• of note.
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