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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
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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
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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
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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