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HomeMy WebLinkAbout1820DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -5 -45 BOX 16 I,yL k-L.'-1 -' I T � Lim T �r `� kP 01820 PUTNAM COUNTY HEALTH DEPARTMENT �~ ' DIVISION OF ENVIRONMENTAL HEALTH SERVICES __r -`_ PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR v.� - _..- ._...- _.... Internal Use Onl. _ - -- _. ❑ Repair Permit issued in last 5 years ❑ �Pdot in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. El Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION /��- �r /yg�_ TOWN p� �pJL" TM # 35 -,t��, OWNER'S NAME /�,��6_ 7 /p_��` PHONE # T�f �j �7ti1r�S` MAILING ADDREESSS- T• APPLICANT Name 8 Relatifthip (i.e., own tenant, contractor] DATE F CIILLITY TYPE f/r"�. PCHD COMPLAINT # PROPOSED INSTALLER T T PHONE # ADDRESS ` I TRATION /LICENSE Proposal (include a sepa to 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. ^,,,� 1AU Ca0o *SIGNATURE I, as owner,agree to the conditions stated on this form TITLE DATE (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE (installer) Proposal apl2roved with the follow onditions: 1. Procurement of any Town PKmft, 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. INTFCINAI I IQ= nPJ1 V Propos pproved Proposal Denied ❑ 14he I ector's Si nature & Title D to //�E- iration Date Re air proposal is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH:--'SERVICES PROPOSAL F®R SEWAGE TREAT{iAEfiIT SYSTEM REPAIR YES RIO Internal Use Onl : 'PERAiitT # ❑ ❑ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ Repair within So yd's Comers, W. Branch or Croton Falls Res ❑ Delegated ❑ ❑ Repair within 200 ft. of ,a watercourse or DEC- mapped at • ❑ Joint Review SITE LOCATION ]et TOWN E!j TM # OWNER'S NAME PHONE # MAILING ADDRESS APPLICANT Name & Relationshi i.e:, owner, tena , contractory GATE LT ' Sl FACILITY TYPE eS PCHD COMPLAINT # PROPOSED INSTALLER PHONE #. ?4d ADDRESS 2 , REGISTRATION !LICENSE # A2�_ Y Proposal (include a separate sketch locating the house property Imes, alladiacent wells within 200 feet of repair and the location 'of existing and proposed system) , NOTE: The Department may require submittal of proposal from licensed,professionai depending on the nature and extent of the repair: s -d o I, as owner, Ve tated on this form SIGNATURE TITLE Q� DATE l owner I, the septic installeliar , to comply with the conditions of this permit brthe septic system repair SIGNATURE ' TITLE DATE d"- _•....__ .. (installer;, Proposal approved with the folloviriM co' loons: 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., 1250:66i. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be pertormed 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 ❑ Inspectors Signature & Title Date. Expiration Date ,Repair proposal is in compliance with'applicable . codes Yes ❑ No ❑ COPIES: PCHD; Owner;.instaiier PC -RP 99ML Rev, 2/07 I I rt V,,,- (\ DIVISION OF ENVMOd ENT- ®F - ==_,,.�..,..:: - HEALTH SERVICES DESIGN DATA SHEET - SUBsuRFAcE SEWAGE TREATMENT Sys -mm Owwr: Address: lidgoi W : SOIL PERCOLATION TEST DATA Wbwnd by: Date Of �: % //J— /s'� DOW of / �6 /J— Nato: 1. Tests to be repeated at.some depth until appoximately equal percolation rates are obtained at each po =lodes to hole- (i.e., _< 1 min for 1 -30 mio/unch, < 2 min&')MRM" All data to be submiNed for review. 2. Dq& measurements to be made from top of hole. -IAN DUP4 �. Fdn�p�g 1 of 2 I I � Nato: 1. Tests to be repeated at.some depth until appoximately equal percolation rates are obtained at each po =lodes to hole- (i.e., _< 1 min for 1 -30 mio/unch, < 2 min&')MRM" All data to be submiNed for review. 2. Dq& measurements to be made from top of hole. -IAN DUP4 �. 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