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HomeMy WebLinkAbout1134DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.56 -1 -13 BOX 11 01134 1 INN , f� Ir ej ,z f OL'} ' 01134 PUTNAM COUNTY HEALTH DEPARTMENT"' , DIVISION OF ENVIRONMENTAL HEALTH SERVICES %�► `.._. PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES No Internal Use Only PERMIT # U 191 Repair Permit issued in last 5 years I U,/Not in Watershed ❑ 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 416 prpw,¢ )eA TOWN Zk TM OWNER'S NAME PHONE #{. ?�(� MAILING ADDRESS 46-(A CEff fZza: APPLICANT e JQ1Tr Name & Relationship (i.e., owner, tenant, DATE S 2v 20 r Z FACILITY TYPE i cS • PCHD COMPLAINT # PROPOSED INSTALLER u- PHONE # 8K, .2 ADDRESS . �9�pk, �(• .CA��.,yg_ REGISTRATION /LICENSE # r Pro sal'(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 stat o i rm SIGNATURE TITLE QI,�,i/ DATE S- ZO • U (owner) I; the septic installer, agree to comply with the conditions 6f't1% e rit for-thd septic system repair SIGNATURE TITLE DATE x:20 (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. Owners 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 ntil authorization to do so has been obtained from the Department. 7 INTERNAL USE ONLY Approved re & Title Proposal Denied is in Compliance with apDlicable codes COPIES: PCHD; Owner; Installer PC -RP 99ML Date Expira or Yes a-/ Ni Rev. 2/07 N22 °43_ =4041 ---Y 5000! / o G .. .. _. . -. _ N Ci , g L O Q, _ ' ETA g x cry r t ;.. a�,� well . J u 4.•x +. P cj ..r y ?' x? Y.'"'`}ss�5..c v i v'. "- s y�y "`�.- .. � <' :. ` •QT s & /dJ �0� ^,:1 � { r > .' 3> �. e ,L£' "� f T i• J'"r '° ts'v s,..,i- _"�:,,k -"g, •e-" Ft y` 3'' a s3 VOi 4 � s c z_ � s � ' �..� } y.3 a `F�, � ^s ��- � �� � � _ � � + s �,r �•�,�. � r �s����e�� ,� ..a.;' � `+fs d v'+' a'3, -'-b3 P 7. czo _r - •° '` z �-• "��• -* •w-- Cci` -c'�` ...:4 �. - --�: rd? �" f ;:, ��ti �b„ Y _ r �" `,�" - ..s't;. ;Am�. a F ai:'�.xz+ • 1 '� L m t t 4y F 4 - . };t d.-t" "�s3 F ,w t 4 '' "'." ; r ,eaY� I! � NIL- 'I-G. ! { r '�� a � ^�"'' � •k�a�,'$ � � %+ ig T ' �7 � � U , TOWN of -1 x F t{ PUT NA M COUN "YORKY j SC E �- 20, Said map filed March 20, /93/ as Mao N °149 -0 • Legend stone retaining wo// wire fence x wires - - - - -• _ - .. ---iron 'pvn 'se1 Putnam County Department of Health Division of Environmental health Services SSTS Repair — Final Site Inspection Date: �/ o �/ 3 Inspected by: ?.�� In Street - Location: 16 Owner: Town: Repair Permit #: 2 — © 7� / �3 TM # .Z S . 67-6 -- / — L3 1. Type of System:. Conventional O Alternate ❑ Comments: 2. Septic Tank Yes No N/A Comments a. Septic tank size —1,000 ... 1,250... other ..... ;t;s. aq b. Septic tank installed level ...................... c. 10'• minimum from foundation ` d. Distribution Box i. All outlets at same elevation (water tested) ... ii.. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches ? e. Junction Box —properly set ........................... C Trenches f i. Systenicompletely opened for inspection /' ii.. Length required Len gth installed 334:57 .. �. iii. Pie slope checked iv. Installed according to plan ..................... / w V. 10 ft. from property line — 20 ft — foundations ... vi: Size of gravel 3/4 -1 '/: " diameter clean ......... vii. Depth of gravel in trench 12" minimum ..,....... . _.. /, viii. Ends capped .... ............................... ./ R. Pump or Dosed Systems 3. Sewa a System Area a. SSTS Area located as per approved plans b. Fill section — c. Distance from water course /wetlands 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box c. Backfill material contains stones <4" diameter ......... d. Curtain drain & standpipes installed according to plan e. Curtain drain outfall protected & dir to exist watercourse f. Footing drains discharge away from SSTS area ......... g. Erosion control provided ............................ << + tSrc's u Additional Comments: RFSI Rev - 011312 - -- � 5r, � 't �sZ 3 Tm as. s�- � � � F .- � �� ��� � � ___ __:_�__�_�__ ~° _-: r �j: ��.�� � �� . _ !,♦ r.... �? _.. i i i f t � �� �. E 9, n — - ..._., . ,_. -- .____..._._�_� _-� � - �� . � F .� � � � ..� r �. ��� � ` r • � P �� t V ' !j � � t 1 � ,y /� __.._���. �' rte. t'�p..C,.. p: n .T' fY t 5 1 a C YATES =t 0 XENIA C .+A tip` .. /� • ��'. � �• � fit' • o IA i )• • � .rte. �^ f rj o ff Y S i R •i I � ' RD EypW710NhFY U a►� . y� qqq ' mi � - .:IRVj S P ,r I'� r k z S gpNl o i t BST D Q: tN _ a A N T 001-7 sue ..... . ..... 4,: LU CC Cz� Q , O I N22-?45-'40"1- 6000 A000� 4. 43 - Ib rs I q ia Over AF /Un_ a At. OP GH Tom' ' S ; T Y Ir I-Alf /UV//V PUT NA /V COUN T),- NEW vOPA' SCALE /"z 20' Said MOP filed March M 1931 as Afoo N9145-0 Legend stone reloining wo// wire fence wires .--iron -Pln,set 2; Y3° 3; /� _ 3;yy 30 z y.�llow i3? l Oaf 4-lel�