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HomeMy WebLinkAbout1110DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.55 -1 -13 BOX 11 01110 JLr 61 9F � Ll 01110 Sent By; MR ROOTER PLUMBING; B 5 635 1173- Apr -28 -08 9:27AM; Page 1/1 APR-26-2008 08:05AM FROM - ENVIRONMENTAL HEALTH — - 845 - ?T8782,1 7 351 P.001/001 F -436 PU'T'NAM COUNTY HEALTH DEPARTMENT DIVISI N-OF- ENVIRCt4M1+MfAL--HEALT SERVICES THIS IS NOT A REPAIR PERMIT'-,, PROPOSAL FOR PLQRATj2N OE SEEIIC §YST�I FAILURE All information below must be "completed prior to any scheduling t I ��i/zv / ..�L•r¢G� SITE LOCATION TOWN O 3M OWNER'S NAMC nn� .,, PHONE #'1, (Lj MAILINGADDflESS 1\ - cLj tAee PROPOSED CONTRACTOR /INSTALLER (Iln 1W ilo i t PHC, NE # ADDRESS 0* �k �,7c���tG� REOIST s -RATIO !LICENSE #' BROM exoloratian• 3S_ • failure to scirfltoe a back -up its houses 0 find limits of system for repair Q other (explain below) FOR_ 00UNTY USE ONLY cL;,r L o� l In pector's Signature & T�tte Da Appointment Date: Tlme: C xlytexa.1.36ptic MEMORY TRANSMISSION REPORT TIME- APR -28 -2008 03:45PM... TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 476 DATE APR -28 03:44PM TO 96351173 DOCUMENT PAGES 001 START TIME APR -28 03:44PM END TIME APR -28 03:45PM SENT PAGES 001 STATUS OK FILE NUMBER 476 * ** SUCCESSFUL TX NOT ICE * ** lm R-t By- MR ROOTER PL_UMBXNO; 8 6315 1173 Apr- '29 -OB ft APR -26 -2008 06.06AIA PROW VIROIBEHTAL HEALTH �� 845278782- 1 T -951 P.001/001 F -498 PU"7 -NAM COUP1'T1C H1= �1 —Tf--1 OEPAFtTM1 =P1"f' - DIVfS{ ��IE�Af.djt�ly'1^�ocL tlAl_- CLi_SSRVICES THIS IS NOT A i�EPAiR P- E- R^-�M -i�1�� • pRaPQSAL FO8 �XPL FiATjL7N OF SE?P'�G SYS'arENl__P__iilS 1J -F#� Alt is+farrr� cation below llsva t ba ft&gi completed (prior to any aCYladUiln0 Qi Pe�ar� 7M w S1T9 I- OCATION �P.v. •} �i TOWN ,y- OWNE:R'S NAME pM0kKa # =1"�'r M.AIUMM AM019Me -S PROPOSED COhfT'FiAG"i•aFtlINSTALlER � �••r; }•�•• T � vti�t:� PH4A[Ea # �Stfj s�� Ste" Lp!'�LJ .. _ AOORESS PQ. 1,S)C% ��QS�f�C4f�Vc(.�IFtEC51STRAT10N J1- IOE_NSE 7R st.�•/� �'SICf'i t --l' to as.aM`aon O 4aialo-sap ire hoaaaa C1 fl—cl llrrilbm oT syabar.+ Yor repslr Cl otw%or tc- pfoir. boloW-1 rRTr t S?at@- Kly�a �.;a. :n epdo CEO C 5l r �O aviland Hollow YP 65 R oh rT" Lake �� Charles r r r r r Mount Ebo ;w Corporate " ORD P5 �/ �utna3;• a Lake,- _ . rnum O'ner 6 57 li " Oq .a"a. C I- Q ti O O$ RD. DR �� CT PARTRIDGE LA NgHD� S 67 66 � r.r• P r r r r QP �y oN Pee rN sir T 4W LA Ytr,9. Corner Pond o WEST KING Sheet / of ' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL -IIEATLII SERVICES " FIELD ACTIVITY REPORT NAME' S NAa91K. T.-I: ADDRESS: // TLOXPzA44L 0 j A),j, Street Town State Zip PERSON IN CHARGE l n-g TNTFRVTFWETI• ChA-Ld l2's/i��lJ1� Thte Name and Title TYPE OF FACILITY: 4ZE����� � a 1111 AN. ._ A " t✓ i_ i / J ✓ I �l e_ Signature and Title RFPnRT RFC- FTVF.T) BY: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: RM 32-f PUTNAM COUNTY* DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE, SEWAGE TREATMENT SYSTEM Owner Address 00� Located at (Street) P,/ Tax Map -75 Block, t, Lot (in to 'neare cross s eet Municipality ) ) 6 r "_s SCI Watershed OIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test nl/o 7 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained attach percolation test hole. (i.e. ,g I min for 1-30 min/inch, s 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 .......... Fiom roun Level Percolation Hole No No, Tune Ela P b n ate Run Start Stop ............. ........... inS a Inches . 60 . .. .. ..... 20 4 2 3 4 �5. 2 3 4 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained attach percolation test hole. (i.e. ,g I min for 1-30 min/inch, s 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 Indicate level at which groundwater is encountered .Indicate level at which mottling is observed IVIA Indicate level to which water level rises after being encountered A174 Deep hole observations made by: �j— !%A(W vAT1 — Date Design Professional Name: Address: Signature: Design Professional's Seal TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH - -- - - .HOLE NO. HOLE NO. HOLE NO. G.L. 0.5' 1.5'� 2.0' 2.5' 3.5' L7a'E,4 y -n', LI Cu V 4.0' 4.5' 5.0' Z/ 5.5' ( hmtS'F�AG -" 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered .Indicate level at which mottling is observed IVIA Indicate level to which water level rises after being encountered A174 Deep hole observations made by: �j— !%A(W vAT1 — Date Design Professional Name: Address: Signature: Design Professional's Seal I 9.3 3q, C O 111 �.v �w(�T3.t2� qv '6k ly - ) vi ......... ... . ^�s.� k BLS . �o. .... _ .._ G l tTA - r4- ON T E Z Po I ------ - --------- ........... ...... . . ..... ... � I .N , �a 1 V iv l i A:4 iLy of 1` Cc f�.*" ,,....•-- � ~; i �`c � l� �- • F. x 36 �v.i QE' i� ^j"' FLT. .....�4.- ._... -_... J(A -f.__ T y PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES R*2-&ED PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR 40 Internal Use Only PERMIT # EA Repair Permit issued in last 5 years [3 Not in Watershed Repair within Boyd's Corners, W. Branch or Croton Falls Res. VDelegated Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION /) %`/ Plyct, TOWN TM # OWNER'S NAME 7 eqc�/ She MAILING ADDRESS _r // T APPLICANT ymrt,; 6:;. %d cc PHONE # Name & Relatidfship (i.e., owner, tenant, contractor) DATE 0-57-- XV-0 f' FACILITY TYPE //V —It PCHD COMPLAINT # � PROPOSED INSTALLER PHONE # ADDRESS 77 RL AvJ�2 /) REGISTRATION /LICENSE # 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 Lv A // pe- ,, Pf° /J. Ar MOkS . P11;-17X n (u vt c. ".t .s-!,l't/ I( I, as owner,agree SIGNATURE (owner) 'I, the septio'instal SIGNATURE � (installer) 7l "A-s �o�as�`�l.� . G'>v.��.s L ,. t� 44- the conditions stated on this orm Gem Ael iv /*-i- ' h�-� e)o► ce: -.k- sp= �•y .b� TITLE ' "' DATE agree to comply with the condititilis of this'permif ffor the septic system repair 4$v A44- TITLE /r' DATE U IULJV -421 OLJVI VVOV VVILII LI10- IUIIVVVIIILLJ %,U1IVILIVIIJ. ,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 backfill d until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Prop sal Appro d Proposal Denied ❑ /'o -4 Z fi /o i . V evector's Signature & Title Date Expiration Date air proposal is in compliance with applicable codes Yes ❑ No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07