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Home My WebLink About1347DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.78 -1 -48 BOX 13 Icy~ �} If J 1 01347 iFrr ;.�. 1 01347 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use PERMIT J� C. ❑ O Repair Permit issued in last 5 years I—] Not in Watershed ❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Fails Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION �,:� f TOWN` �' TM # 2 y "1 �• "' I "'`( OWNER'S NAME s- PHONE #,,Z'9- 3;50 MAILING ADDRESS _5Wi,I, 411 APPLICANT /�- ""' Pt,C_ Name & Relationship 0.e./,44r, tenant, contractor) DATE 1/h, FACILITY TYPE S PCHD. COMPLAINT # PROPOSED INSTALL R l': PHONE # EADDRESS c �Z GISTRATION /LICENSE # f DJ� L nt Proposal pnclude 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. I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) §eptic'iristaller, agree to comply with "the conddions-dTffiis permit fo('the septic system 06*f SIGNATURE TITLE yfi• DATE pnstaller) Pr0RQW with the foll n 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 ®' Proposal Denied ❑ 12— oq Inspedfor's'Signature & Title (/' Date iration Date ,Repair proposal is in compliance with applicable codes Yes 0 No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 �GP PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF. ENVIRONMENTAL HEALTH SERVICES .PROPOSAL. FOR SEWAGE TRIEATMeNT SMITEM R1 11WO SFTE LOCATION OWNERS NAMC MAIUNG ADDRESS VIRLICANT _�. __ ___._. ____.____ L&UL PMW PWMA kWW h" i2a 6 Yom Repaw Wtm Bows c4mem. W, &a%" or 0001= 'tom, 200'L at a eucrvou= cc EJ Donatud 11 j*i"t Aeview TM 4 PHONE if JZY-- towre and amrd of ft repok. 1or , as *Wf W-99M* v- dv condidons on ft 1dfM $10kATURE TITLE DATE (own" I I,-/ 0, the sepk UWaller, agree ID comply iw1kft CMMM Of PSm* ftf ft SOPft $YsWn fSW C. SyMm dewr"lan (0-9., 1260 gal. COXWOW WOC tffi*. M) m 1(mmoeffe ftWW WW pro* ftfflbW syswn MW to be pVbwjod in ao=dW= With ft 810W PMPOW W4 0091111= 4, Ile proposed SM rqw a axwdond a best Bt de Wd 100 to (0 VWMWftG * ft 'IWO" 110 W110 OW conqAstsd SETS rqW vM ftuutam No cogrpUfttl we* iS to be ba6AW uW auVWf&tWW tO d3 so hu bw ab$a!nW *m Ov, Deowt"eK COINES., PCHD: Owner, Onsmiler PC-RP9WL Rev, W Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site Inspection Date: �/ �Z Inspected b : s ��, _ Installer s=i Location _ . _ . ... -- Street- Town: Repair Permit #: / — O * O —! Z TM 7 P — 1. Type of System: Conventional l�'Alternate Comments: 2. Se tic Tank Yes No N/A Comments a. Septic tank size 1,000. 1,250... other ..... b. Septic tank installed level ...................... l/ C� c. 10' minimum from foundation .................. d. Distribution Box i. All outlets at same elevation (water tested) ... in ; ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches C. Junction Box — �ro erl set ........ Trenches i. System �ompletely opened for inspection ii. Length required Length installed iii.. Pie slope checked ... .................... ............ iv. Installed according to plan ..................... v. 10 ft. from property line — 20 ft — foundations ... vi. Size of gravel % - 1 '/2 " diameter clean ......... vii. Depth of gravel in trench 12" minimum.......... _ viii. Ends capped .... ............................... g. Pumv or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per approved plans b. Fill section — c. Distance from water course /wetlands 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box ......................... c. Backfill material contains stones <4" diameter ......... d. Curtain drain & standpipes installed according to plan e. Curtain drain outfall protected & dir to exist watercourse f. Footing drains discharge away from SSTS area ......... g. Erosion control provided ............................ Additional Comments: RFSI Rev - 011312 Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Final Site Inspection _... -. _ � inspected b y:- ' last - -Date: ler: Street Location: `� v fi -j- a- Owner: od�� Town: V 44 e � -re--, Repair Permit #: - TM # 1. Type of System: Conventional C- Vternate 11 Comments: 2. Septic Tank Yes No N/A Comments a. Septic tank size -1,000 ... 1,250 ... other ..... y p I (G-L 4 / b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. Distribution Bog i. All outlets at same elevation (water tested) .. . ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box -�ro erl set ........................... f. Trenches i. System tompletely opened for inspection ii. Length required Length installed Q f iii. Pie slope checked ... .................... ...... ....... iv. Installed according to plan ..................... v. 10 ft. from property line - 20 ft - foundations ... vi. Size of gravel 3/, - 1 %z " diameter clean ......... _ ....... __.. vii: ` Depth of gravelin lieu Ti i�" �riinin►tun .,:::::. - _.._: _.. �C _., _ _. _. . -, ..._ _,_.._ _. _... _ . . viii. Ends ca ed .... ............................... PumR 2r Dosed S stems 3. Sewa e System Area a. SSTS Area located as per approved plans b. Fill section - c. Distance from water course /wetlands 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... `f b. All pipes flush with inside of box. ......................... c. Backfill material contains stones <4" diameter ......... d. Curtain drain & standpipes installed according to plan e. Curtain drain outfall protected & dir to exist watercourse f. Footing drains discharge away from SSTS area ......... g. Erosion control provided ............................ Additional Comments: RFS1 Rev -01 1312 u REBECCA WITTENBERG, RN, BSN Public Health Director - T ROBERT MORRIS, PE Director ofEm►ironmeWd Health DEPARTMENT. OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 : Fax # (845) 278 -7921 MARYELLEN ODELL Courtty Faaecitive TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW ATTN: �'V�n n y 1 FROM: DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED New Application Renewal 0 PROJECT: (' oy r�- LOCATION: TOWN: DATE SUB'D APPROVAL 112-1 Z NOTICE OF COMPLETE APPLICATION DATE: DELEGATED co CN V-1 0 rN m C: O HEI-in-�1t-n ][:�] E toA 0 0 :3 Ln m co CN V-1 0 rN m C: O HEI-in-�1t-n ][:�] -, 2 Ce I E or as no•r:d pc' CoZorr.:.ano.0 I r-U4 izjaLu C t Z� 17 41 + �Umm (T PA>z KING OD I -P, -j 8 2088 6UZVP'y OF P,P(oPF-7P"-T--q- PREPARED FOP- DAV D 2. L-IE7-B-Fa-c; LO -F N105.- 8 2 0 82 - IB 20 8-7 A:5 6 HOW I,J 0Q MAP NB„ OF Pu-rtjAtA LAKE, FtL-F-D MAP NO. (49K -TO\4JKJ OP PA7TER-60k-1 PUTN-IAM Co.; ki.y. 5C ALE I it =30, OCTOBEPI 25-.1984 Ecde,"- '." i-A"a*awr TW7 -k F TOCOMMONI&A—zAL-TH L-AND TITLE 1),JtoURtAAJCC CO. 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