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Home My WebLink About1337DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.78 -1 -19 BOX 13 01337 in Lw T .r L. I I LL 7 01337 _ ... -PR SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT &Z PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES TM Internal Use Only pair Permit issued in last 5 years Repair within Boyd's Corners, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC-mapped wetland % ) e- 4• TOWN O42, rs d� PERMIT # X \— ❑ Jk6t in Watershed ,Delegated ❑ Joint Review TM # �7 1 lS Cl PHONE # Name & Relationship (i.e., owner, tenant, cont� ractm) , /: DATE FACILITY TYPE A66, PCHD COMPLAINT # dam' PROPOSED INSTALLER S�are-se ° PHONE # ADDRESS EGISTRATION /LICENSE # rPe- I8fo- 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 r i r�- v�2 I, as owner,agree to the conditions stated on this form i SIGNATURE �— - �lr�� y �`�r ITLE(,� ,�,�_/� DATE h I/n (owner) - I, the septic' installer. -a iree "to comply'with- the - conditions of this'permit- for'the septic,systefi'- repair' "" SIGNATUR TITLE DATE ? Q (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 al Appr P oposal Denied ❑ - PE Pspectoe's-Sigliature & Title A K Date Expir tion lbate Repair proposal is in compliance with applicable codes Yes ❑ No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 S14ERLITA AMLER, MD, MS, FAAP Commissioner of Health . LORETTA MOLINARI, RN, MSN Associate Commissioner of Health 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. ROBERT J. BONDI County Executive . ROBERT MORRIS, PE Director of Environmental Health DATE: __ OR FIRM: %--094 !�s � PHONE #: PERSON TO CONTACT: eir A'SaVc, czfyc ❑ NEW CONSTRUCTION B + PAIR PROGRAM ❑ ADDITION PROGRAM REASON: . 4J- ROAD/STREET:— I DEEPS: [— PERCS:-Q� PUMP TEST: ❑ TOWNT Pe e , TAX MAP #: �`� " 7 9 SUBDIVISION: LOT #: NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING YES NO __ . _.. ❑ _..__.....❑ Proposed SSTS within-the-drainage basin of -West- Branch or- Boyds- Corner -& . . Croton Falls Reservoirs. ❑ ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. D ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. o ❑ Proposed SSTS fora 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 ,des 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 OUNTY USE ONLY / DATE: 9 TIME: COMMENTS: REQ. FOR FIMM TESTING :KLY 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 (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 ,/ PUT? AIM COUNTY DEPARTMENT OF HE--A--LTH DIVISION OE ENV1.RONME-NTAL..F,-E-A-LTH SERVICES DESIGN DATA SHEET — SUBSTURF-ACE SEWAGE TREATMENT SYSTEM Owner: CAV Located at. (street): On-v,,e Municipality: Address: 17 - -- C, l /'7 TM # Section: :,"Block Lot Watershed: SOIL PERCOLA"' TION TEST DATA -soaldng: Witnessed by: ITsip I P� b H Date of Pre Date of Percola*tion Test: Hole No. Run No.- Time Start - stop Elapse Time (min.) Depth,to water from' ground surface i (nches) Start - Stop W a te r level drop in inches:. I Percolation 11 Rate I min /inch /1 7 1 2 ..7Z 3 LL5- _4 2 3 4 5 3 4 A 2 3 4 ,Notes:. i. ests CO be i -5peated a, same depth until, a T unrox-imatelly, equal percolation a-,,.- obtained, a. each pericoladon zesz hole.•, ke �s I mir, fo-, 1-30 min/inc(, < 2 MIT? 0 m data to be submitted for review. in,,inch.i. v` �Z { r ��A'� tO` 5 & e�'s� �p 7 �3�7 S57 �L-,&t � Mm :y PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE-TREATMENT SYSTEM REPAIR- YE I 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 ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS TOWN APPLICANT..- ---M -� -- M Name & Reiationship (i:e., owner, tenant, contractor) TM # PHONE # DATE ,,,FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER A PHONE # ADDRESS REGISTRATION /LICENSE # .-. Proposal (include a separate 'sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the locatiom' 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. w r << o I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) 1, the septic installer; agree to-comply with the conditions of this'per "fit for'the septic system repair SIGNATURE TITLE DATE (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 ❑ r Proposal Denied ❑ Inspector's Signature & Title. Date Expiration Date ,Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 #!( hz %. d� 79 °/ ® w�Q wQ �� . � F �. ' � - � , ;t' ��",. 5 q rz-,;z ry: c...tt. 45.�� ;t , � r .,�.ct c.r .,��. -• ,'-,, wwt „�;: r x, w-- a.'." ^� w � :7�r.� an1'W'�'' �r� �a 'ra-..,. ..: u*: � 2�-i.. �� ':-X � ,?;k ,'ii. �y,� � _ + PUTNAM COUNTY HEALTH DEPARTMENT �. j , In DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'PROPOSAL-FOR. SEWAGE TREATMENT SYSTEM-REPAIR,- 4 YES NO Internal Use Only PERMIT-# ❑ ❑ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ 5h. Repair within Boyd's Comers, W. Branch or Croton Falls Res. . ❑ Delegated . ❑ ❑ Repair within 200 ft. of a watercourse or'DEC- mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT.---• - -- �f s q)ATE 0 PROPOSED INSTALLER ADDRESS " TOWN TM # PHONE # _ TYPE PCHD COMPLAINT #. PHONE # REGISTRATION /LICENSE # Proposal (include a separate sketch locating a house, property lines, all adjacent ells within 200 feet of repaic.antt the locati�tn of existing and proposed system) 1t.1�:...,,.I: � NOTE' The Department;may'requlre submittal of proposal from licensed professional depending on the nature and'extent of the re ai'r. - � i I I, as owner,agree to the conditions stated on this form SIGNATURE TITLE �► DATE (owner) Z A I, the septic installer, agree to comply with the conditions of thisl permit for the'septic system (epaii SIGNATURE "TITLE DATE (installer) > r s 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 I/o ty, 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repainwill function. — _- . - - - - -- 5. No completed work is to be backfilled until authorization to do so has been obtained from the( Department. INTERNAL USE ON_ LY Proposal Approved ❑ Proposal Denied El i. I Inspector's Signature &Title Date ( Expiration Date !� t Repair proposal is in compliance with applicable codes Yes ❑ 1 No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 1 0 s� (677 Y T . 163.E; fig - ,� All