Loading...
HomeMy WebLinkAbout1150DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.56 -1 -77 BOX 11 104� kol-p I LILL. ME r 01150 YES A PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use Only Repair Permit issued in last 5 years Repair within Boyd's Comers, W. branch or Croton falls Res. Repair within 200 ft. of a watercourse or DEC - manned wetland PERMIT # U Vlot in Watershed biff Delegated ❑ Joint Review SITE LOCATION - TOWN' l a �; j�� TM # OWNER'S NAME k, l,l Oi PHONE #4 914 1 S5 �) 1 MAILING ADDRESS 9 La c -nA rL 'n w i V-.0, .. P G ke r S' on . k1 U I 325 (02 APPLICANT Relationship Q.e., owner, tenant, contractor) DATE % -i - -/1,� FACILITY TYPE POAe PCHD COMPLAINT # PROPOSED INSTALLER ytteS , /r> PHONE # ADDRESS Jr 6 AZ 9/r vim. 0Y REGISTRATION /LICENSE # �y Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 s. feet of repair and the location of existing and proposed system) . , F NOTE: The Department may require submittal of proposal from licensed professional depending on the f r nature and extent of the repair. 4re7w5 ©-F 1 D N `1 /e, k I, as owner,agree,to the conditions stated on this form SIGNATLIREX2�t"k '2- t/- .��,.. TITLE DATE (owner) I, the septic instal r, agree to c ply with the conditions of this permit for the septic system repair ....SIGNATURE- , Y TITLE :��i /a''.. _........_... DATE pnstaller) lowi •o 1. Procu ment 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 ❑ spector's Signature & Title Date Ex ration Dfite ,Repair proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner: Installer PC -RP 99ML Rev. 2/07 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT- MORRIS; P.E.;.MPH - Director of Environmental Health MARYELLEN ODELL County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York .10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 TO: NYC DEPARTMENT OF ENGINEERING AND DESIGN REVIEW ATTN: ;-���� Sty,, -d L, FROM: G ---e-d DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED SSTS Repair PROJECT:_i LOCATION: TOWN: DATE SUB'D APPROVAL: TM #: 26.x6 1 `77 NOTICE OF COMPLETE APPLICATION DATE:. ZZG DELEGATED SSTS REPAIR !7-0 4-f- 4- f .� PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: ".42ez u Address: 12 Located at (street): TM # 7 7' r- Municipality: , /1/ll f C5 o y' Watershed: i�5 , �n 1 SOIL PERCOLATION,TEST. DATA Witnessed by: Date of Pre - soaking: z z 46 Date of Percolation Test: Hole No. Hole depth (Inches) Run No. Time Start— Stop Elapse Time (min.) Depth" water from ground ��° � Start - stolp Water level drop in inches Percolatiols . Rate min/iach �• 1 .,� N 3� 3— ty 30 O 3 9—:23Xi % Go 4 5 1 2 3 4: 5 1. 2 3 4 ,5 1 2 3 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., < 1 min for 1 -30 min/inch, < 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, pg I of 2 0 )r� fames Gagliardo Excavating Cont. LTD. 37 Game Farm Road Pawling New York 12564 V � 1179 Phone /fax .845. 855.3573.. Rr I! Ow/ZS DATE ORDER NO. SHIP TO SALESPERSON DATE SHIPPED $HIP.PEU'U11A F.O.B. POINT TERMS Goa 4 C,-, 1� I I I Uhank lY ®ago Putnam County Department of Health.- Division of Environmental Health Services SSTS Repair - Final Site Inspection Date: 2 �o Inspected by: �'��- Installer: To..�,es Gmd� iarc�o Street Lo tion: .1$4 fe Owner: 1 /�i /Sor1 Town: Repair Permit #:' R-003—,46 TM # 2.6: 1. Was System inspected? Yes No ❑ ' If not, explain: 2. Type, of System: Conventional 9 Alternate ❑ Comments: 3. Septic Tank Yes No N/A Comments a. Septic tank size — 1,000 ... 1,250'. . .'other ..... I Ge b. Septic tank installed level ...................... 4. Distribution Box a. All outlets at same elevation (water tested) ... 5. Junction Box — properly set ........................... 6. Trenches a. System completely opened for inspection b. Length required _,5_0 Length installed__5-4tv c. Pipe slope checked ... ............................... d. Installed according to plan ..................... e. Size of gravel 3/4 - 1 %2 " diameter clean ......... VL _ f. Depth. of gravel in trench 12" minimum ......... g. Ends capped ..... 7. Pump or Dosed Systems �J 8. Sewage System Area a. SSTS Area located as, per approved plans b. Fill section — I c. Distance from water course/wetlands 9. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. Backfill material contains stones <4" diameter .......... c. Curtain drain & standpipes installed according to plan d. Curtain drain outfall protected & dir to exist watercourse e. Erosion control provided ............................ L RFSI Rev - 010515 Jan 14 16 09:40a M J Electric 8455820426 p•1 �s,VIfi ' ay �J-., POW !� op-? 16 1 Ta �Sd`fl gLOn� /'/ ►'rd- 1 -- qi� r SITE LOCATION-4 OWNER'S NAME _ MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES G - - -u I: OFFICIAL USE ONLY 411� ,- 3 C� d TM# r ��5 /� o�.-• PHONE 2 1­'7 S 57 PERSON INTERVIEWED /��-� Gam �r PCHD Complaint # — Aae&c a atlo Ip I.owner, tenant, etc.) DATE TYPE FACILITY 2. 7r PROPOSED STAAER PHONE qi ADDRESS G�� C l`� . �� s °�GISTRATION# 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 may require submittal of proposal from licensed professional engineer or registered architect. I, as owner, or o d e owner agree to the conditions stated on this form. p. _.. _. _ . _..._. ,..... ^ SIGNATURE TITLEYPSI�Er,/ ' DATE ` d 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�bq performed in accordance with the above proposal and conditions. i Proposal approved Inspector's Signature & Title 7D�W COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY SITE LOCATION ` A U C UX(V — br— Jcc "tjUom OWNER'S NAME PHONE', ° 'Tt- MAILING ADDRESS PERSON INTERVIEWED PCHD C plaint # ame Relationship i.e., owner, tenant, etc. DATE // TYPE F CILITY PROPOSED INSTALLER C�- ' J �' - .. . t A r PH F S �°Z .� 5 � �709J ADDRESS REGIS TION# Proposal (include sketch locating all djacent wells): NOTE: Repair must be in same locatio and of same type as on al sewage disposal system .Different location may require submittal of proposal from lI ensed professional ngineer or registered architect. i %- ) Lo J _ I as owner, or re . - rteda , ent -of owner agr _to the c dirions_stated on this form,. - -- - SIGNA Av, TITLE Proposal v th fol 1 i i 1. Procurement of any To permit, if applicable. 2. Submission of as buil epair sketch in duplicate sho ' g: a. Owner's n e b. Site Street ame, Town and Tax Map number. C. Location f installed components tied to two fixed ints (e.g.,house corners). d. Syste description (e.g., 1250 gal. Concrete septic , three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above pro sal and conditions. Proposal approved_ \ Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 9%E r R- 31-16 c) a • CO, _ • MXJ 'c 4