HomeMy WebLinkAbout1147DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.56 -1 -68
BOX 11
r 11 11
1 1 1
-o
I�yL�
,�,
1
J _
�l
•�
11
�I
''
�I�
1
.
J
��
-
9,
I
T
1
�
r
`i
I �`
TF
�,
a a
ma
1,
+Lh
01147
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE . LOCATION " CO&104- PL/nvAH (•-f( --TM #,
OWNER'S NAME iM o ti d d'''l � &51 N LCOI� EW42! �-
MAILING ADDRESS 21 ,IA-N 62!74U5<E 1-ALe P- -D i-A-
OFFICIAL USE ONLY
'119" 2 3 v -d3
—/ 1(0./
PHONE 9< 73 2- -
PERSON INTERVIEWED J)LA,'uL 6L� PCHD Complaint #•
J Name & Relationship (i.e., owner, tenant, etc.
DATE ib /t 10
TYPE FACILITY.
PROPOSED INSTALLER title -iA-0-4 PHONE Z-7
ADDRESS REGISTRATION#
Proposal (include sketch locating all adjacent wells):
NOTE: Repair'must be in same location and of same type as original sewage disposal system .Different location
mayrequire sulbmittal of roposal from licensed professional engineer or registered architect.
Azz a-mdj - �nZgvK
I, as owner, or reported agent of owner agree to the conditions stated on'this form.
SIGNATURE TITLE 0-)A/ 1A/ (n e DATE t 0
1
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission 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 components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
16ATE'/
X X 189.0>i~
i
stone W
3.5'Nr9h
Y
' \.
N X ti 7 }s a►
5751
5706 • 570D Oro
\ is 2."0e D
V.
Putnam County Department of Health
de- P)geCO D ly tr a ' ,/ `DivisiiO oC P /Environmental Health Services
Approved ds tote ?or confornarco yr "_r
n, N ) :•I applicable Rules and Regulations of t2.c
I. • f .,f U �lth D_a;�artm en .
L ' � � \._) •�, \' ., ; +) ' . . Sicature m Title D-
� 1•
— ��- ---- - - --- -- - \ ---- - - - - --
bIwut LAG n. -WWW
20-00 R - f9>i1Q0'
1. - �6.2d' Ce fCP 207.!0
WJN W. �e.M1 WOff c. 20+.r 24 °CW
aval!re. iee�s 2r'a► '
Sc41e I' =Z o'
Owncrs, y�PtEOFN }09 Cr►ginaer�n9 by:
Mohamed f A.l;colc B�na�ss4
°s C c Ju 1 pus 1. Ca54 r�? P�
9 '
rvwn o f P4��croan ` ,, p
0 Blackberry Dr.
(�u/fnan,,wCo. , N. y ��ap. o. 4i�26..:���r 914= 479- 7115
7M _ 5 P.I -G9 ®213. ROFESSIONP�
sans a►wac Dwfe : Jqn, /3� 1999
1 A /999
1k
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION Of ENVIRONMENTAL HEALTH SERVICES
1 PROPOSAL FOR SSOM DISPOSAL SYSTEM REP dw W
6
SITE LION "All k' VA-
MAILIW ADDRESS D 0
PERSON PCHD Complaint #
Nam & Relationship (i.e,, owner,,teriant, etc.)
DATE TYPE FACILITY
-
PROPOSED INSTALLER of, PHONE k v 7
REGISTRATION #
Proposal (include sketch loca�ing all adjacent wells):
Nam: Repair must be in saw -location iihd of same type as original sewage did*=11 syttem.
Different location may regure submittal of proposal from licensed professictal -eg -mew, or
'registered architect.
P
Imp
-S-,,--,7 _X,
Proposal apnpnr Proposal Disapproved
7
Inspector's Signature & Title
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission 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 ccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 deep
drywells surrounded 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 er, or re!!rted ag of owner agree to the above conditions.
SI TITLE
Wuu(MV; YeUcw (Tim El); Pink (ApPUmt)
DATE
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'J
DESIGN DATA SHEET - SUBSURFACE SEWA -GE TREATMENT SYSTEM
Owner . Address
Located at (Street) � A-ca w tV. Tax Map Block I Lot 9
(indicate nearest cross street)
Municipality 0���' y . Drainage Basin;;
SOIL PERCOLATION TEST DATA
Date of Pre-soaking I v16 r Date of Percolation Test ! z
Hole No.'
Run No.
Time
Start - Stop
se Time
n.)
De th to�Water
rom Ground
Surface (Inches)
Start Stop
Water
Level
Dro In
Inc�es
Percolation
Rate
Min/Inch
7.J
3Q
J� 14,
.7.
-2, 7
3
3
4
5
1
/ 5'6 2; z6
��� ��i-�
„ Z
r,
4
Y
5
y�P
yob
2
3
i
4
�4A . 4�
f
5
SIO
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 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
f Z n
1
DqA XI
Form DD -97
0
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH
G.L.
0.5'
1.0' .
2.0'
2.5'
3.0'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
:... 9.0'
9.5'
10.0'
HOLE NO. / HOLE NO. 2 HOLE NO. 3
g2 r
AA-
61, Ste„
Indicate level at which groundwater is encountered Na ^,
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered --
Deep hole observations made by:O , 40 cam' Date
Design Professional Name. uc `- /*,r c
Address: G JO fLACZ< 4 `2
Sipature:
Design Professional's Seal
C-1
A �
ROFFSSIONP�
X 14 / X to o.O4
V.
r^3 to -G
3 5 `Na9 h.
X 1 J1Da �-- • ,
I /
5�
/ ✓
lY .
a�.3.7
to /
V.
9ars�r w,a�a T o
all
f <.
S71Z /
+$714
VaL PM 04M j
2O3oas
P _ \ is
fi
q• ,. tnam County Department of Health
r✓ 1f-F !e e- F)AI6- Cy � o !/ Diviojol of Environmental Health Services
APProved Zed for conformar ce vi—,
rnT �' �oc A� /3N CAX /I/'Nl� + %r applicable Rules and 'neg,:lattona o?, t:
�_ I I. "! , !, ::'•a iU ith epartmen
1:. .,�, . , Signature m Title D
3'1,62-
Now
2D00' R • op4a c>d rrx 2D7.lO
}p L - i*26' iJNgX[. ZOf.94 2� "CMi
WJN W.1l�.TI
Wart. We." 24"Off
Sc41e 1 " =20'
0 WhG►^3. �SPtE OF N 9 Cng lneerin9 by:
a'
Mohamed d Mcole 8ena%ss ��s c
4 qF Ju IIUS 1. Ces' are, P�
o.,, o f paiienwn ;; e , &..4 Blackberry Dr.
R O2N6P� ; , C�`rtu ✓ re ws �e ; � Y
/05-0-9
' u na n Co. AJ 00 -. 41� 9/4 =7-79- 7115
11 7— — S6- i �Gi ® 213. ESSI
sans awe .Dbfe : JAn, l3, 1999
X 189.09
7.
MA
t
57'�Yle. wo
h
x 1 f •/ ,,
a Z'%V�a 1l.
-� 93 y
I 1 .c.
I O� /
N x1117. S. 7 N
5'158 � / . !' �• ..
5708. 5f09 S>90: 5. 5712
f :
I
I 'I\
®
mu Pa ate
r I
� `\ :k 2113.06
SPCC,AL #67- r 1.
J•. Putnam County Department of Health
(/r!/ s^4ufr �t� P1AeFro iY a' `Divieio I of Environmental Health Services
�
gpproved�hoted for oonfornance, k
applicable Rules an3 &eb,aat.;ona of ti;)
Put e
/ I. / :. /..::'. lth D aartmen .
P:hcc.'�LtC� ys`
.. . Suture i Title D d
w 7,
'1
00644___ - -- — — ` . \� ----- ArfW IA A'- co-war
�ACONA �OAO' / R .f'tf74O'
� J/ � - Cb IM
207.0
M711 W. SH y� M7 OUf c. 20+.9 24 "CW
avatare. lean z~r'ar
Sc4le I' =Zo'
Owners. SPt�OF N }o [�glneerin9 by
\\3s 11 9 �Ju l i us 1. C 6s4 r� P06
Mohamed f Al;colc Gana %ss4 � 'F /
rvwn o 1�4f��r�o/7 0 BlackbGrr`y Dr.
Al ^ W $Q / ✓/e►�wsTer AJ y Joso9
t)u,Afna�n^ /Co., Ny ��Op.No.41126..:��2� ✓ /`T -7.79 -7115
T -M _ J 6.1 —GJ 3213. RO-,ESSIOWP, I
MPS 0Vmm pb�-L : ,JQn^^. 13, 1999
/999