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01234
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'v PROPOSAL FOR SEWAGE DISPOSAL SY'STE1MMPAIR'J
OFFICIAL USE ONLY
SITE LOCATION/
OWNER'S NAMEi
MAILING ADDRESS
4,& -.7 e C/"' . ,/�� � TM# �S` 11'4' 14 /C)3
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PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
TYPE FACILITY ol-�' —�'
DA
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PROPOSED INSTALLER PHONE Z° 3 " 7%� — 2 $d/�
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
may require submittal of proposal from licensed professional engineer or registered architect.
,4 Xr 6,-TIC11
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I,. as.owner, or reported agent of owner agree.to..the conditions. stated on this form.
SIGNATURE Rtn.K TITLE DATE
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 comers).
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
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DATE
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTION PERMIT
NAME OF OWNER: STREET LOCATION:
REVIEWED BY: RM, GR, AS, SRDATE:
Y N DOCUMENTS
C_)C__)PERMIT APPLICATION
,(_)(__)WELL PERMIT OR PWS LETTER
UUPC -97
(__)(_JLETTER OF AUTHORIZATION
(__)(___)DESIGN DATA SHEET (DDS)
C__)()CORPORATE RESOLUTION
(_)(_)SHORT EAF
(_J(__) PLANS -THREE SETS
( J( HOUSE PLANS - TWO SETS
(__)( JVARIANCE REQUEST
SUBDIVISION
(_)(_)LEGAL SUBDIVISION
()C_)SUBDPJISION APPROVAL CHECKED
C__)C__)PERC RATE
(_)()FILL REQUIRED DEPTH
C__)C__)CURTAIN DRAIN REQUIRED
GENERAL
(__)(JLOCATED IN NYC WATERSHED
C_)(_)PLANS SUBMITTED TO DEP
(_)C__)DELEGATED TO PCHD
(_)(_)DEP APPROVAL, IF REQ'D
C_JUDEEP TEST HOLES OBSERVED
(__)(__)PERCS TO BE WITNESSED
C_JC_)EX- APPROVAL SSDS ADJ, LOTS
C_J(_)WETLANDS (TOWN/DEC PERMIT REQ'D ?)
(__)(_)DATA ON DDS PLANS & PERMIT SAME
(—J(_)PRE 1969 NEIGHBOR NOTIFICATION
(_)(_JLETTER BI/ZBA
C_)(___)100 YR. FLOOD ELEVATION W/I200'
-)�' SGIL 7ESTING-LO T S>10-fEARS' OLD '
REQUIRED DETAILS ON PLANS
(--)(JSEWAGE SYSTEM PLAN - (NORTH ARROW)
(J(__)SSDS HYDRAULIC PROFILE
C_J(_)GRAVITY FLOW
(_JC_JCONSTRUCTION NOTES 1 -15
()(DESIGN DATA: PERC & DEEP RESULTS
C_JC_j2' CONTOURS EXISTING & PROPOSED
(_J(_JDRIVEWAY & SLOPES, CUT
()(JFOOTING /GUTTER/CURTAIN DRAINS
(-J(JUSDA SOIL TYPE BOUNDARIES
C_JC__)TTTLE BLOCK; OWNERS NAME ADDRESS
TM #, PE/RA; NAME, ADDRESS, PHONE#
(_)(_)DATE OF DRAWING/REVISION
(-JUDATUM REFERENCE
C_)C_JLOCATION OF WATERCOURSES, PONDS
LAKES,WETLANDS WITHIN 200' OF P.L.
((_)PROPOSED FINISH FLOOR AND
BASEMENT ELEVATIONS
C-J(- __)WELLS & SSDS'S W/IN 200' OF SSTS
(�CJPROPERTY METES & BOUNDS
(__)(_)EROSION CONTROL FOR HOUSE, WELL &
SSTS, EROSION CONTROL NOTE
COMMENTS:
(REVSHEET)09 /01 /00
TAX MAP #: (CONFIltMED)
Y N (REQUIRED DETAILS ON PLANS CONT'Dl
(_)(_)HOUSE SEWER - Y" FT. 4 "0'; TYPE PIPE CAST IRON
UUNO BENDS; MAX BENDS 45° W /CLEANOUT
RENEWALS
(__)USTTE NOTE (NO CHANGE)
FILL SYSTEMS
(__)(_)101 HORIZONTAL; PAST TRENCH SLOPES 3:1 +TO GRADE
(_)(_)FILL SPECS/ FILL NOTES 1 -5
(__)(FILL PROFILE & DIMENSIONS
()()FILL IN EXPANSION AREA
FILL GREATER THAN2 FEET
U(___) CLAY BARRIER
(_(_)FILL CERTIFICATION NOTE
(_)(_)DEPTH GAUGES
(_)(_)VOL. ON PLAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS
(__)(___)SEPARATION DISTANCE FROM TOE OF SLOPE
TRENCH
(__)C__)LF TRENCH PROVIDED 60FT MAX.
(__)(_)PARALLEL TO CONTOURS
(_)C_)100% EXPANSION PROVIDED
(___)(JDETAH,/DUST FREE CRUSHED STONE OR WASHED GRAVEL
C_JC_)GEOTEXTILE COVER
SEPARATION DISTANCES ON PLAN - FROM SSTS
(_)(_J10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL
(_)C__)20' TO FOUNDATION WALLS
(_)(_)100' TO WELL, 200' IN DLOD, 150' TO PITS
(___)0100' TO STREAM, WATERCOURSE, LAKE (inc. expan)
(_)()50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
C_J()10' TO WATER LINE (pits - 20')
L )� )50' INTERMITTENT DRAINAGE COURSE.:
(_,(_)200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS
(x()10' MIN TO LEDGE OUTCROP
SEPTIC TANK
(_)C _)10' FROM FOUNDATION; 50' TO WELL
WELL
(_)(_)DIMENSIONS TO PROPERTY LINES
(_)(__)LOCATION OF SERVICE CONNECTION
(_)(__)MIN 15' TO PROPERTY LINE
SLOPE
(_)C_JSLOPE IN SSTS AREA (S20 %)
(_)(,REGRADED TO 15 %, IF REQUIRED
DOSE/PUMP SYSTEMS
(__)C__)PUMP NOTES
(__)( _)DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED
()()DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
(_JC_JPIT AND D -BOX SHOWN & DETAILED
(_)( _j1 DAY STORAGE ABOVE ALARM
CURTAIN DRAIN
(--)( _)STANDPIPES, 5' BOTH SIDES, DETAIL
MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %,100 % -<1%
(____)(__)20' MIN to CD DISCHARGE /100' with 182 cons day discharge
(_)(_)10' MIN to NON - PERFORATED PIPE
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