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HomeMy WebLinkAbout1109DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.55 -1 -11 BOX 11 01109 ., , ' i %J L� 1� 01109 PUTNAM COUNTY HEALTH DEPARTMENT ¢� DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAI YES NO Internal Use Only' ❑ Repair Permit issued in last 5 years ❑ Not in Watershe ❑ �. 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 tc ,/ Cdr TM # OWNER'S NAME d el-vz-. Fll:: fj er; Z PHONE # MAILING ADDRESS, APPLICANT J0,io ` Name WKelationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER �) h'I-' '� <<f� PHONE # ADDRESS t!�,lAe 1 C 7,e., ,4 �. t'/ REGISTRATION /LICENSE # v 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 trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional enginee or registered architect. ey 72 ri I, as owner, or rep rted agent owner agree to the conditions stated on this form SIGNATURE �'� �� TITLE)'" Proposal apci ed with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name �;. b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) . • e. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and condition . Prpposal Ap oved Proposal Denied 4) 01 V'spector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 DATE IV-to ---- J 4 v,r> r�' z -e _ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE' SEWAGE TREATMENT SYSTEM Owner: -�Z�°y j ���.(�z - ✓fy Located at (street): Municipality: 4erl Address: TM # Section: _ Block _ Lot Watershed: k s'f 5 &z SOIL PERCOLATION TEST DATA 1 ! r / Witnessed by: Date of Pre - soaking: I t Date of Percolation, Test: Hole No. Run No. - Time Start — Stop Elapse Time (min.) Depth to Water from ground surface (inches) Start - St/o" water level drop in inches Percolation Rate min /inch /� LL 3 : o__> 4 5 1 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., < I 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 I of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # 0 ! HOLE # HOLE # HOLE # HOLE # G. L. 1.0' 2.0' 2.5' 4.0' l ! v 5 4.5' 5.0''�' 5.5' 7.0'+ ;,µms ✓�' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered ' i• Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: !' ., , d J� Date Design Professional Name: Address: Signature: Design Professional = Seal 12/01/2008 08:06 8458553573 GAGLIARDO EXCAVATING PAGE 01 4 •.. NOV- 24-2009 04:40PM FWENVIRONMENTAL HEALTH - SHERI -ITA AMLER. MDS M%-FA;gP_ __...__..... C"OMIJ 95ibnel- Of Nealth LORETTA MOLINARI, RN, M5N Associpre Cbtnml9SIOne0- Of Health 8452787921 DEPARTMENT OF HEALTH 1 Geneva Road, Breve r, New York 10500 l�OC1E�'I' P'QR ���� 'Y'ESTING T -299 P.0011001 F -651 ROBER"f J.-- RONi3I COW10, �@rwklivc ROBERT MORRIS, PE Director of.Environmentq( H41anh -w All informiistiO10 1)MOT" must be f„L11Y completed prior to any schedulina. DATE: % off` ENGINEER OR P'11V(:CeAcU PRO PERSON TO CONTACT!_,- �►.�- �a © NEW CONSTRUCTION aRfPAIR PROGRAM Cl ADMON PROGRAM REASON: DEEPS: J'ERC,S: 011- Y&P TEST: ❑ ROAD /STUET:�CAa"z-q e L'\t 9--) ,.... »...,.__ TOVVN: v TAX MAP*, T SUBDIVISION: LOT #: NYCDRP ciuT.ERtA FOR JOINI RVI M AM WITNESSING of 5Q& TESTING YES. NO 4 Proposed Si within the drAb4fte Wait; oi"West Branch or Boyds Corner & _...._._ ............._....... _...._. Croton fans Reservoirs. © Q/�FrvpoW 3$TS within 500 feet of it reservoir, reservoir tam or control lake. O ��Zyropofiad opo#W SSTS within 200 feet of a watercourse or a DEC wetWd, © SSTS design flow m eater than 1000 gallons /day or SPDES Permit required. © Proposed SETS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing, The Department will determine the NYCDEP project status (Joint or Delegitted) based un the response. If you answered 1!es to any of the gaestlons, NYCDEP must witness the soil tests, This DePonment will coordinate a mutually suitable time for field testing with the Design Professional and NYCDBP. If a project lag bocn determined to be Delegate4 based on tho above response and then subsequent information ilndleates NYCDE.P is required to witness the soil wsU, it will be the sole respoulbility of the desig 1 professional to schedule rt- witnessing of the soil testing with KYCDE)'P. ® FO COUNTY USE ONLY DATE, COMIl2li IL r2Q roaazzD 110 Orssv Environmertul tlnaltil (845) 278-6)30 Fax (845) 27& -7121 Water Supply 54021aa (845) 223 -5156 Fax(945)2!-"-.541R Nursing Serviner (945) 278.6555 Fax (845) 278 -0024 WlC (8+15) 278w0678 Nursing Home Caro Fax (W) 278.6085 FArty lotervention/PresahooT ($4S) 278 -6014 Fax(043)278-6649