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Home My WebLink About1390DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.81 -1 -9 BOX 13 rU 1�1' 1 ii" F 1 ,y �, I I 01390 YES O PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR _ ' ; _ :'l+,: 0 �. __ SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT 'A Internal Use Only PERMIT # Repair Permit issued in last 5 years LJ 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 LT Joint Review �g0 t Akv- U,, ,,TOWN eA _ v TM # n Q U M U 4-ko PHONE # 3 9 U Lv+ L.- .< L ogee Q2 i le , Q 2ea.1Skk A) V l ' 5-0 % Name & Relationship (i.e., owner, tenant, contra r) DATE 9-30-0- FACILITY TYPE ReS PCHD COMPLAINT # PROPOSED INSTALLER M f !« s 444-00aSCO-V i`c.C5 LL C- �HONE # `I y g6 5-7,9 y ADDRESS OC-Sed el' Ott/cs G,1-,,�C 60-e- JS4kREGISTRATION /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. ^ s i i r_ 4 .. 11 1 e 1 1 a_ &4 ex-Fir-4L I, as owner,agree to the cl tions stat Is form SIGNATURE TITLE 0w-.2 DATE Z L (owner) I, the septic installer, agree to comply with the. conditions of -this. permit for the septic system.,repair SIGNATURE ACV2.f4 _ TITLE aj►Je�lt-( f� DATE -30112- (installer) Proposal aaoroved with Ze o llowing 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 Title is in Proposal Denied with apDlicable codes Dat4 I Yes fia No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 � eve � �-�. e�� . �� _ � � �� AM` C Sheet . of . PUTNAM COUNTY DEPARTMENT OF HEALTH+ - ' -` - :....:- `: -- .'DIMSION -OF ENVIRONMEIgTA� HEA"TLH- SERVICES _ . __ ; ._ .. _ . _...._....._�.. - ��'Iy YO4 FIELD ACTIVITY REPORT NAME • N TZ® Tel: er�r�nFcc• -3w ZaR 6 Sa8'TZF - i A-7- TAT --;��/ Street Town State Zip PERSON IN CHARGE OR TNTFAR VJP- r). (Z y 12A 7-10 Name and Title TYPE OF FACILITY' FINDINGS: 3 -= lid Signature and Title I acknowledge receipt of this report: .TURF: 02/96 R ev _ 1 �Dm 14- {v� a�� -1 v Signature and Title I acknowledge receipt of this report: .TURF: 02/96 R ev _ a�� -1 v Signature and Title I acknowledge receipt of this report: .TURF: 02/96 R ev _ ;• • •: .tea'•'' "'. .r. r i p i ' 'A -C 18' B -C 35 A -D 27` B -D 41';.::: `.' E'er: Lees ec�',e �.. AN -E 34' B -E 17.5' it .. ' .. r.•�� . �' , , . A -F 26.5 B -F 21 ` :... ,. r a B -G 29.5 A -H 60' B -H 31'•,x, A -I 57 A -H 29 F, G & I ARE INSPECTION PORTS i :t b :7 :r '�Y �• w { I' �i ryry •i� 1� . i' Environmental Protection New York City Department of Environmental Protection SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR DETERMINATION Pursuant to the authority granted under: Article I 1 of the New York State Public Health Law; Rules and Regulations For The Protection From Contamination, Degradation and Pollution Of The.New York City Water Supply and Its Sources, 15 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR Appendix 75 -A Wastewater Treatment Standards- IndividUal Household Systems; Putnam County Septic Repair Program Plan -- March 2005. DCP Project# • PCHD Repair# Site Location:34'0 L�� c�' � �� PdAe "Jo T.M.# F5 P1 Reason for Joint Review: Drainage Basin 200' of WC /Wetland Repeat Repair in 5 Yrs. Name of Owner: Owner's Address: Q-s Drainage Basin of Project Site: �asf ✓' "C� Installer: bl4e-s Ado 0V SPVV &t-s General Description of Sewage System Repair: �J, X5.1 i`-s Dates of Site Inspections and Soils Tests: Approved v "Incomplete Delegated **Denied ' "Required: Soils Tests Repair Sketch WC/Wetlands Wells Other ":'` Reaso Determination made by: Engineering Division Date OKME SITE MAIL. PERSI f 7+V R. - - -- - Pro (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 yrofessional engineer or registered architect. ,.n � G73��v�7 1�6 u 1 s- � �9% f. i 1 Proposal approved Inspector's Signature & Proposal Disapproved 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 d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. Dgte (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE OW Z t TPIFS: indite (PaD); YeUcw (Tbm Ell); Pink (kVUa3nt) DATE hIr 4t, PUTN�0/1. COUNTY DEPARTTIVIENIT OF HEALTH DMSION OF EINVIRON�[EN-TAL HEALTH SERVICES DESIGN DATA SHEET -'SUBSLa11FACE SEWAGE TREATtiEENTT S --YSTEN-f Owner; -,M.0L,1gz-6 Address: 3130 LAY-65 Loc.ated at (street): T-M r-r" Section:-'-5B10C",- 3 Lot Municipality: 'P,42]n9ZZ--,0A/ Watershed:_ }� Aac SOIL PERCOLATION TEST DATA . e*o[Pre-soakin-. Witnessed by: Dat Date of Percolation Test: -. 2Z5- Ho I e No, Ruo No. Time Start— — Stop i Elapse T'im e (min.) Depth to water from ground I surface (inches) -St.2 rt - S t 0,P NY'at er level drop io inches 2 .3 .4 3 4 3 4 .3 4 'No C es: T-c7--. ,r,, 'na r P7-r?n' C. L. o. lip] 2. -9' 2. 51' 3.0' 3.5' 4. "1" 4.5: h i1 8. 0' G. T'EST'-PIT DATA I)E*SCP,IPTI* I u�SuuS-ENicu :--TEST-=E-S-- H'O L E 4 HOLE # — H. 0 L Z # Lridlkate !ev�-! at w dch v-oundwaler is enlcou-'--1ered Indicate lev .- !at which -motilln'- isob seried Irldiciie Level to which water tevel, vises a:-L,-r, beina- encocintered D"n hole obsl-rvarion-, rnade b.-v: Da --.e Des'LQ7,. ProtesSional 'N--am (Z' Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Final Site Inspection Gi a v y e V /7c, Date: `f12- -1 /!2 Inspectedby: Installer. ",1 /zs co 5,t vice s Street Location: 310 I-all Town: f a rr: w Repair Permit #: Z - 1 i3 l TM # x t�- . I 1. Type of System: Conventional ❑ Alternate ❑ Comments: 2. tic Tank Yes No N/A Comments a Septic tank size 1,0 1,250 ... other ..... +/ b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d Distribution Box i. All outlets at same elevation (water tested) ... v / ii. Protected below frost......... ` ' iii. Minimum 2 ft. Original soil between box & trenches e. Junction ftx - Obperly set ............................. f Trenches, i. Systeni :ompletely opened for inspection ii. Length required Length installed iii. Pipe slope checked ....................... ".......... iv. Installed according to plan ..................... .v. 10 ft. from property line = 20 ft - foundations ... vi. Size of gravel % - 1 % " diameter clean ......... vii. Depth Qf gravel in trench 12" minimum ......... viii. Ends capped 9. Pump or Dosed Systems 3. Seware-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. Backfll 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: �a 1Lc n �W4t : ,},o ccp w.4elt:k-Z o� �z "r" cea. RFSI Rev - 011312 I Cie > eeV.A ep V, (> U, Environmental Protection New York City Department of Environmental Protection SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR DETERMINATION Pursuant to the authority granted under: Article 11 of the New York State Public Health Law; Rules and Regulations For The Protection From Contamination, Degradation and Pollution Of The New York City Water Supply and Its Sources, 15 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR Appendix 75 -A Wastewater Treatment Standards - Individual Household Systems; Putnam County Septic Repair Program Plan — March 2005. DEP Project# PCHD Repair# Site Location:370 �g � '� . �e'J � T.M.# ate• �i -�- �( Reason for Joint Review: Drainage Basin 200' of WC/Wetland Repeat Repair in 5 Yrs. In Name of Owner: 9,46 c,'t/,,, Owner's Address: `�'uc, Drainage Basin of Project Site: 6 asf . - Installer: f/� /r'��f �'^�fd�uy Spvy/cQ,S General Description of Sewage System Repair: ,ail 2, U J�, PrY V i k sG �e �v��y °tJ -e Xtf4�y Ss 7 ". i Dates of Site Inspections and Soils Tests: Approved. *Incomplete Delegated *- 'Denied '!-.Required: Soils Tests Repair Sketch ::,`Reaso WC/Wetlands Wells Other Determination made by: Engineering Division Date SHERLITA 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 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW PRIORITY - SEPTIC REPAIR DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM JOINT REVIEW PROJECT: 3 g® 'I-Age �j4o-ZE D'iZ7; TOWN: SUB'D APP DATE ,,/T/W NOTICE OF COMPLETE APPLICATION: DATE: q / V❑ Within the drainage basins of West Branch, Boyds Comer Reservoirs or Croton Falls. �/ Within 500 feet of a reservoir, reservoir stem or control lake. ❑ Within 200 feet of a watercourse or a DEC wetland and appearing on a subdivision map approved after December 31, 1992. ❑ Design flow greater than 1000 gallons /day. ❑ Commercial SSTS. jtreviewrepair 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 Far (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DI MION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information must be Ju lly completed prior to any scheduling. Date: 20 - /-Z Engineer or Firm: ill kC s u. o i'c�s VAhone #: _ 17 1 q 6 114 57ckep Person to Contact: _ (r-)a g �4 ❑ New Construction D Repair Program Cl Addition Program Reason: Road /Street: D Deeps . Q Peres ❑ Pomp Test 4v Town: Pig -fe.5 C3y`' l Tax Iblap #: Subdivision: Lot #: Owner: ❑ Project not within NYC Watershed. NYCDEP CRITERIA FOR .TOOT REVIEW AND WITNESSING OF SOIL TEST.i11G YES NO ❑ ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Soyds Corner reservoirs. ❑ ❑ Proposed SSTS ,within 500 feet of a reservoir, reservoir steno or control lake. Q ❑ Proposed SSTS within Zoo 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. This Department will determine the NYCDEP project status (,joint or Delegated) based on the response. If you answered Zes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for Held testing with the Design Professions 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 Hof the design professional to schedule re- witnessing of the soil testing with NYCDEP. .i FOR COUNTY USE ONLY DATE: TIME: i COMMENTS:- Req.for field testAly 4/16/2009 I YATES e- k4s,-O�nl tit, mum: u; x4 JES W REO FtD LA W— PO WF ,ixw A K ' . – 41A-M c3 000 400 - ./�i�- u� Alwo 000 400 - YAHM' S TAME ME LOCATION s +TAILING ADDRESS ?ERSON IATE 7 PROPOSAL FUR SEMM DISPOSAL SYSTEK REPAIR TYPE FACILITY oposal (include sketch locating all adjacent wells): VM: Repair must be in same location and of same type as original sewage disposal system. Afferent location may require submittal of proposal fran licensed ofessicnal engineer or ,registered architect. .0 Gpl� A u Ir a/, G12.., )roposal approved -� r Inspector's Signature & Proposal Disapproved ?roposal 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 Strut Name, Tbwn and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 125G gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. as owner, or reported agent of owner agree to the above conditions. UGNATURE TITLE CW v &, DATE t l W: Wiite (P®); Yellow (Tan BE); Pink Ug2jo knt) r. w �z OP g f I A " C \/