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PUTNAM COUNTY HEALTH DEPARTMENT 1 ��
DIVISION OF ENVIRONMENTAL HEALTH SERVICES d
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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 Comers, W. Branch or Croton Falls Res. Delegated
❑ lam-' Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NA
MAILING ADE
APPLICANT
TOWN TM # fJ� ' (o - I -X
7
/ Name & Relatiorighip (i.e., owner, tenant, contractor)
DATES ® B FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER !�"� ���� ��.,��_ PHONE #
ADDRESS 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. /
tAJ/ 1 d'GLi/ 'e, Gl vl CA At,/
I, as owner,a to th conditions sta on this form
SIGNATURE ITLE `gin -s-�/ DATE • i, l - `y A
(owner)
- •I, the -septic i aller, agree to comply with the conditions of this permit,for the septic_ system.repair,
SIGNATURE % ^ TITLE r, DATE
(installer)
Proposal aoproved with the following conditions: f
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 Department.
INTERNAL USE ONLY
jinr al Approved .���'" Proposal Denied ❑
04 0 // C
or's V ture & Title f Date Expiration ate
,Repair proposal is in compliance with applicable codes Yes 0 No. .
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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McDonnell
34 Interlaken Rd
Patters ®n
'fax reap # 25.64 -1 -26
R- 293- 09
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EXCAVATONr+. CONTRACTORS
e •• 6
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RNP MSN
__. AssoCiate'Comnrissione-i' vf'rlZaltfr _~
ROBERT J. BOND1
County Executive
ROBERT MORRIS, PE
- - - . _ Director -of Frzvironmental -Realth- _ -. -- • -
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
REQUEST FOR FIELD TESTING
All information below must be fully completed prior to any scheduling. DATE:' 1 d
ENGINEER OR FIRM: T PHONE #:��'�
PERSON TO CONTACT:
❑ NEW CONSTRUCTION ❑ REPAIR PROGRAM ❑ ADDITION PROGRAM
REASON: DEEPS: C" PERCS: PUMP TEST: ❑
ROAD /STREET:
SUBDIVISION:
TAX MAP #:
LOT #:
NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING
YES NO
0 ❑ Proposed SSTS within the drainage basin of West Branch or Boyds Corner &
Croton Falls Reservoirs.
Falls . .. ........ .
".a, ,Prannsed,SS�'$ withia.500 feet of a reservoir.,'.xeservolr.stem :ar :cpnta;c�_l_l-ke.._.._ -
❑ ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
❑ ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required.
❑ ❑ 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 ygE 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: TIME:
COMMENTS:
LEQ.F0kRELDMTfNMXLV 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 (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (8'45) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
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