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BOX 11
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01117
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�j PUTNAM COUNTY HEALTH DEPARTMENT
(� DIVISION OF ENVIRONMENTAL HEALTH SERVICES War
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES NO/,, Internal Use Only PERMIT- #`_`= ..6 q
Li LJ / Repair Permit issued in last 5 years Li ot in Watershed
❑ . Repair within Boyd's Comers, W. Branch or Croton Falls Res. elegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland-,C>,,;,,,, ❑ Joint Review
SITE LOCATION TOWN 0. of AJ TM # :55-1-33
OWNER'S NAME T;;UM%\ PHONE# fiys --a7? ^a76
MAILING ADDRESS �Z _S 66- A.,det f5oA) /V y 1,54-3
r
APPLICANT.
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE . � & ' PCHD COMPLAINT #
PROPOSED INST LL RY TY�( /'per PHONE #..,
ADDRESS c REGISTRATION /LICENSE # /130 I
ems^ O L
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 Ed extent of the repair. j� p
4. nla� ,•���,,,� � tiP�c,s wl flP� r. boo aa lro.l
...r. ► .
I, as owner,agree tgLhe 99nd#tipns stated on this form
SIGNATURE TITLE ��%) erl, DATE
(owner)
I, the septic installer, agree to com ly ith t0V conditions of this permit for the septic system repair
SIGNATURE TITLErr r* <- DATE
(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
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
Inspector's Signature & Title
is in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
:Dat6.
codes Yes
No O
Rev. 2/07
PUTINAIN/1 COUNTYDEPARTIVLENT OF HEALTH
DIVISION OF EN1VrRO_1NN1_E_NT_kL HEALTH SERVICES'
DESIGN DATA SHEET -'SUBSURFACE SEWAGE TREATINVIENNT SYSTEM
Owner: Address: S'6
.2-S' .5i6 t 33
Located at (street' ): TlM Section: Block Lot
Municipality; 'Pa/ Wate-she&- (C 14
SOIL PERCOLATION TEST':UATA
Witnessed by:
Date of Pre-soakinri. s/
��Xz:Date of Percolation Test:- SVIZ f ZIW
Hole No,
Run 'No.
4
Time
Start—
-stop
Elapse.
Time
(ruin.)' in.)
-Depth to
water from
around
g
surface
(inches.)
Start - Stop
Water
level drop
in inches
Percolation
Rate
min/inch
7 n&, Y21
3,5,
1 _2
lm"_To
1 � 3 —4:AV L, aZ
j�
G3
-.
.3
Ilz4a 2t
J- o
2
3
2
3
4
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED [NNTEST HOLES
C L H'O LE HOLE HOLE
HOLE
e-, e
2 .0'
5cL�
2.
IA'5
4. C'
J -
7.0'
7.5
8.0'
8. 5,
LS e:icoLL-jjer,,
Lndicate leve! at w1iichl a-zoundwai-tr' d
Liclicate level at w�jch mot�in� is obseried A/
Inidicar2 I.ev--[ to w�mch water [eve.1, rises a�zze.-, beina- nucoUn--te"!d
Den hole observatioms rna& by: r1a -1-zej R C-Date
L_n profess:orLal Na.-Ln.,.-
Addr�-ss:
c�
-nat*.r,
Sheet 1 of 1
Putnam County Department of Health
• Division of Environmental Health Services
Field Activity Report
Name: _Toymil Telephone:
Address: 56 Slater Rd Patterson NY
Street Town State Zip
Person in Charge or Interviewed: Date:
Name and Title
Findings: R- 098 -11, The septic appears to be installed as per plan. Pictures to support
Inspector: (� V e-'' Telephone:
Signdfure and Title
Report Received by:
I acknowledge receipt of this report: Signature:
Title:
Field Activity Report: cw Date:
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11411 NA MIT
Sheet of /
PUTNAM COUNTY DEPARTMENT OF HEALTH —f—
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
A1)T)RF4.e 46 'SLAr9K To*2 1��1TT.�?ZS� ail
Street Town State Zip
PERSON IN CHARGE
Name and Title '
TYPE OF FACILITY: S im ig
FINDINGS:
Signature and Title l
RF_P_ORT RFC`.FTVF.T) BY:
I acknowledge receipt of this report: SIGNATURE;
02'/96 Title:
o
,veil
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Signature and Title l
RF_P_ORT RFC`.FTVF.T) BY:
I acknowledge receipt of this report: SIGNATURE;
02'/96 Title:
05/12/2011 21:14
APR -01 -2008 11:08AM
19737646404
FROtKNVIRONMENTAL HEALTH
S14MITA ANLEP, MD, MS. FAAP
COmmLsB%Oner of Health
LORL -ffA MOLINARI, RN, MSN
Associate Commissioner of ftalth
ALLCOUNTY
8452787821
DEPARTMENT OF HEALTH
I Geneva Road, Syewster, New York 10509
REQUEST F (JR FOLD M,TYNG
All information below muar be I Iv completed arior to any scbedukag.
-U%'fr-s
PAGE 02/02
T-144 P- 002/092 mu
ROSERT J. DON131
County, acuttua
ROBERT MORRIS, PIE
Dkeatar of E"Vironmental Heolth
DATE: 913 II
MK , ENGINEER OR FIRM: �a t� i� PHONE #: '` ���
PERSON TO CONTACT: f , l a
❑ NEW CONSTRUCTION dJMPAM PROGRAM 0 AIiDMON PROGRAM
REASON:
ROAD /STREET':.
DEEPS:0' PERCS:,T�t'r
.5-4 �> fa%cr ko�af
FUW TEST: 0
TOWN: ,� cr „ �, iU "? TAX MAP * .15. 53_ /
SUBDIVISION: LOT #:
UWiNtic IMA_r4rz _— LOVIV11
NYCDEP CEMRIA ROR .TOW REiMVY AND M I IAING, OP 90I1. TING
YES NO
d t� Proposed SSTS within the drainage basin of West Braneh or $ay& Corner &
Croton Falls Resmvofrs.
❑ �E. Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
o 4 Proposed SSTS within 200 Feet of a watercourse or a DEC wetiaod.
in 0 Proposed SSTS design flow greater than 1000 gallons/day or SPIES Permit required.
0 ilk Proposed SM for a Commercial Project.
It is the respousibility of the desist professional to provide the above information prior to soil testing, The
Department will determine the NYCDEP project staters (Joint or Delegated) based oil the response. If you
answered, to any of the questions, NYCDEP MUA witness the soil tests. This Department wQ1 coordinate a
mutgally suitable time for field tcslfag with the Design professional and NYCDEP.
If a project has been determined to be Delegated based on the above response and then sub"nent.
informatioa indicates NYCDEP is required to witness the soil tests, it will be the sole rMTonuffifllity of the
design professional to schedule re- witnoming of the soli testing with NYCDEP,
OR dUNTY USE ONLY
CQ1tig1�IV �Irl'�+�a
Ra IUfI[M20TPSTD7 AY Enviranme tpi Heutth (843) 376.6130 Fax (845) 378.7921
Water Supply Secdon (84 5) 225.5136 Fax (845) 32x5418
Nursing Serviea (845) 279 -W8 Fax (H45) 378 -6026 WIC (945) 278-6678
. Nursin2 [tonne Care Fax (R45) 378-60$5
Enriy lntarvcoCoo /Prembool (645) :7UDi4 Fax (845)178.6648
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PHONE ,;Z 747- -7A94-
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PERSON INTERVIEWED Pam Caq)laint #
Name & . Relationship (i.e, awner,tenant, etc.)
DATE A fh/ TYPE FACILITY
J( 'B� — —
'79-75 &5
PRi,0POSED IMT U, PHONE -2
Pr6posal (include sketch locating all adjacent wells):
NOM: Repair must be in same location and of same type as original sewage disposal, System.
Different location may require submittal of proposal'fran licensed professional engineer or
register architect.
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Proposal ap
,pr-a—vg;
Is
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94 Ard UC,- 451101,
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Proposal Disapproved
61 6
/ A
t Dfite
toposal approved with the following conditions:
1. i Procurement of any Town permit, if applicable.
2. Submis.jion 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.camponents tied to two fixed points (e.g.,,house corners),
'd. System description (e.g.�,.1250 gal. concrete septic tank,, three precast 61 diem. x 61 deep
drywells surround.ed.by one foot + gravel).
,e. Installer's name and number.
3. 'System repair to be performed in accordance with the above proposal and conditions.
as owner, o reported agent o er agree to the above conditions.
;IGNALTURE .4� TI= DATE
US:! VlAte MD); YeUcw Mkin 91); Pink QjpUcant)