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HomeMy WebLinkAbout1119DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.55 -1 -36 BOX 11 01119 . 1 , a C ' L 1, , La ■ I 01119 PUTNAM COUNTY HEALTH DEPARTMENT a DIVISION OF ENVIRONMENTAL HEALTH SERVICES` PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES NO Internal Use Only PERMIT # ❑ Repair Permit issued in last 5 years ❑%Not in Watershed ❑ . / Repair within Boyd's Corners, W. Branch or Croton Falls Res. LEI Delegated ❑ L� Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION AC>aA TOWN d.'f'�e U11 TM # 364 38 OWNER'S NAME h� t-c f ), t C) e QQ PHONE MAILING ADDRESS fi tPAtcd) ,P r 1 0o%..4 ,k i's eJ4,, c.r , A I V APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE —oz FACILITY TYPE �I<� PCHD COMPLAINT # PROPOSED INSTALLER Yell-h 60115/- .1r2C- . PHONE #,61W -6 Z$- ,5_UE6 ADDRESS ZL6 U�I�S� /o /% e�1/�� 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, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE 4 (owner) I, the septic ins I r, agree to comply with the conditions of this permit for the septic system repair a SIGNATU TITLE DATE 3 "' (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 Denartment. INTERNAL USE ONLY Proposal Approved IZ Proposal Denied ❑ 8 107/,07 /Z. /2.7 0 Inspector's Signature &. itle Dat Expi tion Efate Re at proposal is in compliance with applicable codes Yes Y No ❑ COPfES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 � opo c�Ctl 6 — -- -"' !'"" " -r`0 _ HEKLA CONSTRUCTION, INC. Y LIC: # PC33 WC- 11762 -HO1 246 Buckshollow Road a Mahopac, NY 10541 A � ID box .53 � 330 u►? -��. 33o u to 3V :3 1) blDx . 3' � opo c�Ctl 6 — -- -"' !'"" " -r`0 _ HEKLA CONSTRUCTION, INC. Y LIC: # PC33 WC- 11762 -HO1 246 Buckshollow Road a Mahopac, NY 10541 AUG 31 '07 11:42 PAGE. 001 D,,P -� - ro I�r: -;wal Cp�e�S�ee� 3 � a� eS ► h� d- \J A m �LN o r =� we C1 410 . ug r r no CD 00 __�4%pN i _ Located: M (V) Owner /Applicant Name: DO[DA �(` /� TM`s { ,Block Lot � 31 Formerly: Subdivision Name. Is system fill completed ?_ Is system complete? y" , Is system constructed as per plans? Is well drilled? y Is well located as per plans? Are erosion control measures in place? S Subdivision Lot # Date: ^ Date• ••` ; Date: I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued- PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date:-1-3/-07 Certified by: llt�"ckHh 6,nsT,��, PE RA Address: 0 C S�of�oc�: /t[� Uc. # M&PLO FOC wy r osvAl/ Comments: Form FIR -99 ** 300'30dd 1d101 ** PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION RE( UFST FOR FINAL IMSPEC rION For. Fill All information muss be -fully completed prior to any 'Trenches Inspections being made. P CHD Construction or Repair Perm it # 6 / Located: r`rh lv1 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL, HEATLII SERVICES FIELD ACTIVITY REPORT NiAlyM.- Teti: Sys' - ;L7 9 - 3 9 1 Street Town State Zip Y •;.i�i l PERSON IN CHARGE nR TNTFR VTF T): QUA G©AU!67 , natP 8 ./.2 2-140,7 Name and Title TYPE OF FACILITY: -geP/4 -/ Z rR C %wo � FINDINGS- r e- - 141 le o21 8 22 0 7 Signature and Title RFPnRT RFC FTVF.T) RY: I acknowledge receipt of this report: SIGNATURE: 02/96 Rev . ►sul � � Cam' Sheet _of__� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT Street Town State Zip PERSON IN CHARGE OR TNTFR VTF—WF.T1, T)atP: Name and Title TYPE OF FACILITY: —/ZCOWE 1 s -Jl v� 5,5 4e.- IrV1546 Na Signature and Title REPORT RF[FTVFT) By: I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. J P_IJTNAM ' CO-UNTY DEPART1d ENT OF HEALTH DWVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner �1'�L?So�% _ Address 5 � � f7=,OA V Located af`(Sireet) - Tax'Map,55131ock _� Lot 36, (indicate nearest' cross street) Municipality- per¢ � �t Watershed Aeea-ts 7- TjMA,&jc -k SOIL, PERCOLATION TEST DATA Date -of Pre- soaking a: 07 -D-ate -of-Percolation Test 8,�.z !&7 r -/ ... 1 9 06 =9,�� f' !9 %- z3 5 P/' -p- 1 91/6'- 7:19 . 13 -36% °39% .3 9;3P Vlf5. l '36'. 59 3 3 17 36- 3 -�o 3 5,7 4 5 1 '2 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. s 1 min for 1 -30 min/inch, s 2 min for-3 140 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top.of hole. - Form DD -97 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health 1 Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTING All information below must be fully completed prior to any scheduling: DATE: ENGINEER OR FIRM: f7� co S)"- ' PHONE PERSON TO CONTACT: ❑ NEW CONSTRUCTION WREPAIR PROGRAM ❑ ADDITION PROGRAM REASON: DEEPS: PERCS: ❑ PUMP TEST: I P005e- ROAD /STREET: _ ye��e r R V X a 70 -TOWN:. SUBDIVISION: n y f na wl L a k�e LOT #: OWNER: DQr f� I/ h - P eAv f S ©1) I 27 *9 NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING YES Nge ❑ 'Proposed SSTS within the drainage basin of West Branch or Boyde Corner & / Croton Falls Reservoirs. ❑ t1 Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. El ❑ % Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ d/ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ GY Proposed SSTS 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 Delegated) based on the response. If you answered ves to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professional 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 USE ONLY DATE: 0/;L-2—(F 3!oo TIME: __ / 40 COMMENTS: REQ. FOR FIELD TOTING:UY - - Environmental Health (845) 278 -6130 Fax•(845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax ($45) 278 -6026 `WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 1 )� t I OV, 0 "� 68 _ iv46and ollow - fATE$ 't7t7" XENIA Y°UNG ittle; and `O t uirce mum mers Lake Charles r r r INW Putnai Lake pNER RDJJ `.l 9Q 66 �t 67 . 9 O O 7 t RD 5 %- oPo OT 4W JIA o O 9Q [vim