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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SY
YES N Internal Use Only
❑ Repair 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
SITE LOCATION.
OWNER'S NAME
MAILING ADDRESS
APPLICANT A G,
PERMIT #�: —�
Vot in Watershed
elegated
❑ Joint Review
—/_S3_
Name & Relationship (Lb, owner, tenant, contractor)
DATE -7/0 FACILITY TYPE PCHD COMPLAINT # _h
IF
PROPOSED INSTALLER 9 -01"J"VA PHONE #
ADDRESS 1'7/ &4lerc. ellrl PQ REGISTRATION /LICENSE #
L,Jh I 434-c_ PV_ Proposal (include a parate sketch I catingRn a use, 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 dep endirm on the
nature and extent of the repair. ���(d►�l J
NFL l _ n.1 �i JL_ -7r0-,r,& . 2 i cam. /Il r ' YV e.w i� R'�• oN / J�f
I, as owner,agree to
SIGNATURE
(owner)
... . . (.- 1.1 C-- If- ,
the,gbnditions stat is form
r TITLE C DATE o2c9v
agree to co y ith the conditions of this permit for the septic system` repair
SIGNATURE TITLE D-4-"iN'07%- 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 ApploWd/1 I o Proposal Denied ❑
- In pector's Si
e air ro o:
COPIES:
PC -RP 99ML
A17- _ I /-j ": od�
nature & Title A �,` Date Expir tion Date
a
31 is in compliance with applicable codes Yes ❑ No r
PCHD; Owner; Installer
Rev. 2/07
i
r I
PUNY`
LANDSCAPE AND CONSTRUCTION
191 LAKE ELLIS ROAD
WINGDALE NEW YORK 12594
PHONE/FAX 845-832-3810
CELL # 845-222-1239
KEELER
4 KINGSTON ROAD
PATTERSON MY 10509
r2J
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iwitrEc, /,q y
08/31/2009 15:20. 8323810 PLM PAGE 01
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
REQUEST FOR FIELD TESTING
All its c>rmation must be: ull corn feted prior an scheduling. Date:'
f .P P Y g /
Erigi ,heer gar Firm: Phon #:
Person to Contact: 3-
i
C7 New C:onstmirtion Repair Program 0 Addition Program
Reason: Deeps;:. .14 Peres []'Pump Test
.toad /Street: l /,14y s4uw P.) 4-1
'I'own: �r� �'�,s, a,� i�' �-/ ! 1)5.0 Tax 1Vlap #:
Subdivision: Lot #:
Owner: /h r-S / m.-e, /�2
•lProject,not witht'n NYC Watershed,
NYCDEP CWTIE�# FOR JOINT REVIEW A.N- -V ITNESSLNG OF -SOIL TESTING
YIES NO
❑ Proposed SSTS within the drainage basin of West $ranch.'Croton Falls, or $oyds Corner
reservoirs.:
❑ Proposed- SSTS within 500 feet of a reservoir, reservoir stem or control lake.
(� t7 Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
( CI
'Proposed SSTS design flow greater than 000 gallons /day or SPDES Permit required.
❑ Proposed SSTS for a Commercial Project,
le. is the responsibility df the design professional to provide .the above information prior to• spoil testing,
Tifis Department will dkermiaP the NVOTF -P project st7tus (Joint or Delegated) based on the response:
If, you answered cs to any of the questions, NYCDEP must witness the soil tests. This Department will
Oordinate a mutually suitable time for field 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 of the
design professional to schedule re- witnessing of the soil testing with NYCDEP.
FOR COUNTY USE ONLY
-bA- 1<: TIME:
COMMENTS_
Req.for f1c1d tcst:kly 4/16/2009
AW
-ARED ANU
A GENCY
AW
X1
PUTNAM COUNTY DEP-A-R OF HEALTH
DI VISION OF E-NlrIRONA/IENT-�:.F,'E-A.LTH SFERVICES
DESIGN DATA, SHEET - SUBSURFACE SEWAGE TRE-,4,TMF-.WT SYSTEM
Owner-
Located at (street): Ila
Municipality:
Address: 0-A
TM # Section: Block Lot
Watershed: z
SOIL PERC, OLATI ON TEST DATA
Witnessedby:
Date of Pre-soaping: Date of Percolation Test:
Hole No.
Run No,
i
Time
Start —
Stop
(
Elapse S
Time
(min.)
Depth to
water from.'
-ground
surface
(inches)
Start - Stop
Water I -Percolation
level drop Rate
i inches
n min/inch-
ali41
3 b 1
�2'3
17
�2
.3
4`
5
2
'2
3
4
I. 3
4
NO Ee s
1. Tests to be repeated at same depth until arvro:rimamiv 5aualjoercciatjon rates are
obtained a, each percolation :asZ 'noie. (i.e., < 1 mir, for 1 -30 min/inch, < 2 min for 3': -big min/inch i.
data to be submitted for review.
2. Depth measurements to be made from ton of 'ho[t,
i
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