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HomeMy WebLinkAbout1936DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www. s ca n y o u rd o cs . co m 631- 589 -8100 36.23 -1 -64 BOX 17 rm i� i �, ��. T;r �T ,. qr �`' i`r� r, I '-r ■ �. h i I. 01936 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 00 LAk.gJn PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR _YES,. , _ s.NOz ./ _ _�. _b......., - >.__ .,:•�. ; ` InternahUse+Onlyf LJ Lff Repair Permit issued in last 5 years Li " In vvatersnea ❑ / 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 TOWN errs Q— TM # 36. 23-(- V OWNER'S NAME ,�y¢/, ��� ��r j PHONE' o,�S3° 6,'Y� MAILING ADDRESS « Xr �"S�✓ APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATES/ FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER 1AJ0 Op/ �?/l�!' PHONE # 1y f ADDRESS IXJ� 4, / /'o', A Z , ;ZH, — /Wn P- 7REGISTRATION /LICENSE # 1 Z Cq G2.s`6� Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 (6,,J 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 SIGNATUREp,,�,.n�s� d•'o TITLE O cvn,� DATE � Ar (owner) I, the septic installer, agree to I w he conditions of this permit for the septic system repair SIGNATURE TITLE DATE (installer) Pro osal a roved th I win 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 Proposal Denied ❑ lZa I spector's Signature & Title Dat / Ex irati Date Repair proposal is in compliance with applicable codes Yes B- No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 � d Sey.i;� �?z"!4__coo .....:.�..__. __._...1 �b - -.13► Q_��. E.�'�'.__. �-�Q� fir,_ _ _____ _— �..... _�,....._._........- _.__... - - -- bN, Fil kv, I Sheet_ of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES -I R -FIFLD-.AC.T,..,V ITY,�,EPORT-,,,.... AT)DRESS: & AEdZ0,iCf- I>C, RaL� A Street Town State Zip PERSON IN CHARGE 1, nR TNTFRVTF.WF.T); A t Name anff Title TYPE OF FACILITY: '16 FINDINGS: � TS A /11 -, - It -.., i Signature and Title REPORT RECEIVED EY.' I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. 5- 3 LZ2 V S, 3-5: I-q,42, Signature and Title REPORT RECEIVED EY.' I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. Pataam County Depertmeet of lily Dlvisloa of lovlim"00 *80alth Serviees yd's 3l /y Mt T3 kej sm f air — nun SUe 1s�ap�tlOO © � r Dam: /' In by: 6 Installer: /,ya od /a L L C Street . // .E &e.`ie r. Owner: tA" o-rdc, - _. d�ca svn� . - - Rol P -� -f�� ��,*/ .. TA4 # "3<0: -.� I. Type of System: Convendonal Alternate 17 Comments: Z, I Yes INoINIAl - Comments L Sepdc lank size — 1,000... 1,250 ... other ..... �.� /fns Old ground Fad w log c `Zise� � .Lf ed' b. Septic took ladled level ...................... ee p wf l=1� od,�j/a�- Pes e- le c. 10' n ftm foundation .................. . -4:5 4cxl1 eeQ r e p a d �- C. s 1-0& as d. L AM outlets at same elevation (water Seated)... ii. Prooecosd below fine ............................. iii. MWounn 2 & Original soil between box & e. set ............................... f L loom far ingpection V7 ii. LMWh rpieed Length installed 2 0 imos /,I-. Iii. Pbe slain chocked iv. Imbued according to plan ..................... v. 10 & Am property line — 20 ft — foundations n vi. Sias of gravel % -1 K " diameter clean ......... vli. Depth of `ravel In trench 12" minimum ......... viii. 3. a. MW am as Par lags b. c, couradwetimuls 4. Oveniffait s. " Hoxm pwurmly pouted and installed con ocdy ........... b. All pipes fimh with inside of box .......................... 3 c. HaclA maiesiat contains stones <4" diameter ......... d., Curtain drain & shndpipes installed according to plan e: Curtain drain ouW protected A dir to exist watercourse f. Footing drains discharge away from SSTS area ......... • g. Eosion control provided ............................ e; aye See ee Additional Continents: RFS1 Rev - 011312 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: L� ,4 ►Z� f� Address: j/ 2!5�4/"'E (� Located at (street): Municipality: �t2� N Watershed: SOIL PERCOLATION TEST DATA Witnessed by: / 2e cf Date of Pre - soaking: Date of Percolation Test: i 1-7 11'cl Hole No. Hole depth (Inches) Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min/inch 27 1 4 ;F0 U; 03 -r" 3 U ;y - 0 1� '���' 14,7 -34 �. 5 1 2 3 4 5 1 2 3 4 5 1 2 3 I 4 5 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min/inch, < 2 min for 31 -60 min/inch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97, pg 1 of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # { HOLE # HOLE # HOLE # HOLE # G. L. 0.5' y.. 5- 1.0' 1-14A 1.5' 2.0' 2.5' 3.0' 3:5' 4.0' 4.5' Qle- Sala 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered v Indicate level at which mottling is observed A)OA IF, Indicate level to which water level rises after being encountered Deep hole observations made by: 1���..�C _ Date 711irl Design Professional Name: Address: Signature: Design Professional's Seal_ Revised July 2013 d® eo4e- 13 j ? awce tA YATES Niol Futna job REO 19-C. '18 PMN 13 W Rr ba& -g cop - --------- _-------------- - - - - -_ I b+� . ... . . ........... ... ........ -01 1 Li Ho p c 4� y _____.___._..___,_....__ _.--- ____ -� ._________._.___ mss__- c_o__- _____•____.__ .r___.._�..____._._.__.._.._.__