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HomeMy WebLinkAbout1331DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 25.78 -1 -2 BOX 13 I L II :; , �6 ', r� ' 116 1 ' r 1' 'r 4 5 F . �� . WIL IL , 01331 PUTNAM COUNTY HEALTH DEPARTMENT Rik, D DIVISION OF ENVIRONMENTAL HEALTH SERVICES 9,4 ' PROPOSAL FOR SEWAGE_TREATMENT SYSTEM REPAIR , YES NO Internal Use Only PERMIT # .3• ❑ Repair Permit issued in last 5 years ❑of in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. I Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION �, l ✓'- a �,v�- TOWN , jam - M # JIM � 1Z OWNER'S NAME PHONE # MAILING ADDRESS APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE �7- FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER 2,zrwi� rW-A., PHONE # �_ ADDRESS''} ytryL ,�.v.,4�. B�£.Lr�^ �.AAi REGISTRATION /LICENSE # `Ot5Z% Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 12. 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. _ A /000 Coo' I, as owner,agree to thee conditions stated on this form f SIGNATURE % L„ ": L / a/ /"-VG %y TITLE &-W)i ', fl DATE (owner) r• -- -- -I; -the septic installer, agree to comply -with the conditions of this permit for the septic system repair . SIGNATURE Z-� TITLE DATE 7 - 7,o/ (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. 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 Dr Proposal Denied ❑ Inspector's Signature & Title Date Expireftion Date Renair nronosal is in compliance with applicable codes Yes 121/ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 22, %21 L 7- zo e0mev" It 0,00 AQ t Putnam County Department of Health.- Division of Environmental Health Services SSTS Repair - Final Site eIInspecction Date: z b S Inspected by: (. tc -cceC Installer: Street Location: Owner: Ajy %le y` Town: - -."Rz A,r6e te... - - .Repair Permit i#:..._ .- ?, °/ _TM #.. 1. Was System inspected? Yes No ❑ If not, explain: 2. Type, of System: Conventional 01 Alternate ❑ Comments: 3. Septic Tank Yes No N Comments a. Septic tank siz - 1,000 . 1,250 ...other ..... I . /p ©a cites (� (/� ,k o� b. Septic tank installed level ...................... 4. Distribution Box j a. All outlets at same elevation (water tested) ... 5. Junction Box - properly set ........................... 6. Trenches a. System completely opened for inspection b. Length required Length installed c. Pipe slope checked ... ............................... d. Installed according to plan ..................... e. Size of gravel 3/< - 1 % " diameter clean ......... ...._..f . Depth of gravel in- trench 12" minimum .. ,...:,. , ..... - - ...... _... _..._ -- g. Ends capped ............. 7. Pump or Dosed Systems 8. Sewage System Area a. SSTS Area located as per approved plans b. Fill section - 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 & du to exist watercourse e. Erosion control provided .................. ........... RFSI Rev - 010515