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HomeMy WebLinkAbout1976DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.31 -1 -58 BOX 18 01976 Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Final Site Inspection Date: tr/-3.0 3 Inspected b —/ P Y: G1 • 11.4a Installer: � wacs l i QA ► l e M � Street Location: y� r j�rL Y - - � P"er: - -• -,fie, � y �. - - `b s - Town: Repair Permit #: ft. - to Y 9 - 6-1? TM # 36. 3 / 1. Type of System: Conventional C(Alternate O Comments: 0-, 9 9faa� pv,rep $ 5-9+y /c, 14�wks 2. Septic Tank Yes No N/A Comments a. Septic tank size -1,000 ... 1,250 ... other ..... �jtjs�lt.� b. Septic tank installed level ...................... C. 10' minimum from foundation .................. d. Distribution Boa i. All outlets at same elevation (water tested) ... ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches e. Junction Bog -0o erl set ............................ f. Trenches i. Systenitompletely opened for inspection ii. Length required -t 4o Length installed 90 C4G 1� o iii. Pipe slope checked ... ............................... iv. Installed according to plan ..................... V. 10 8 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 .... ..........................:.... . R. Pump or Dosed Systems 54 ct3 3. Sewa e System Area a. SSTS Area located as per a roved plans b. Fill section - c. Distance from water course /wetlands I- 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 - f � SJ r let II _ PUTNAM COUNTY HEALTH DEPARTMENT �� DIVISION OF ENVIRONMENTAL HEALTH SERVICES L , . .....r_ -._. RR ®P4SAL-FOR SEWAGE;-��R-EATIIftENT �- XSTEIVI� REPAIR YES NO Internal Use Only PERMIT # `0 ❑ / Repair Permit issued in last 5 years ❑ /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_n<<.;, 4,yr ❑ Joint Review SITE LOCATION ` or1ss.)1/1- fll- TOWN s%7`c40.1 fi- _ TM # 6.31 OWNER'S NAME 1ti4 Jgt^e-T PHONE # MAILING ADDRESS 2//3,7 P/,,,hs J� Wyld,h &/ APPLICANT .79mcs C ��rt�� �i►.s7� %J� Nam Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE JLlyMe PCHD COMPLAINT # PROPOSED INSTALLER PHONE #'yJ' ADDRESS 37 Am. ��`�� REGISTRATION /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. -. sue" I, as owner,agree to the conditions stated on this form SIGNATURE ���rr TITLE ©cam DATE - (owner) I, the " septic instal er, agree to comply with the conditions of this permit for'the septic"system repair SIGNATURE %+±� �' TITLE �nf�d' DATE (installer) Proposal a r ed with the followina conditions: J 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. iurGOUei i Ql= nuu v Proposal Approved Proposal Denied ❑ <Z _ 3 13 s Inspector's Signature & Title Dat Ex (ratio Date ,Repair proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 U b�o cs9! Prof _ �.� -is7� n � T G �✓r7 - -� _ �` � •- - / - -v S4-Y -_ -tf /,uvt _.__.c✓��ir (��KCCW !��1) �/h �iG4/ � /!" ✓jc .; G( /S'' J-N S�-j�1 Gkil% i I I I + a �uuAdcf 2. PUTNA 4 COUNT'S DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATVIENiT SYSTEM Owner: Address: W, Located at (street): TM 4 Section: _ Block ___- Lot Municipality: dt, P.0 ��yt Watershed: s4- f�lccytG� SOIL PERCOLATION TEST DATA Date of Pre - soaking: Witnessed by: i Date of Percolation Test: Hole No. 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 1 7 0 1XhA "' I 2 j 3 4 f I 2 - 3 I 4 � l 2 4 ' 3 4 I 5. 2 � j 3 4 Notes: t. Tests m be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < I min for 1-30 min/inch, < 2 rain for 31 -60 min/inch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form TEST PIT DATA , DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # HOLE # HOLE # HOLE # HOLE # G. L. 0.5' 1.0' e� �f� A) ;l (c- r�✓t 2.0' �— °r,�to K 2.5' e- le- y ,',P vL a.S 3.0' m v, 4.0'�� 4.5' o,n/l vd 5.0' 5.5' fee k �cr r✓J� 6.0' J' 6: 5' 0J- � CMG e,Vl e-i �l " 7.0' 7.5' 8.0' 8.5' 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date / Design Professional Name: Address: S i mature: Design Professional = Seal