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HomeMy WebLinkAbout1990DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.31 -2 -40 BOX 18 y r .r II L Ll 7 Lr ILL � Lo ` - Ir i . - , %L ELL P UTNAM'COUNTY HEALTH. DEPARTMENT G-i ✓ was %/ DIVISION OF :ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM. REPAIR. YES NO Internal. Use Only PERMIT ❑ V/Repair Permit issued in last 5 years of in Watershed ❑ Repair. within.Boyd's Comers, W. Branch or Croton Falls Res. PDe . legated Repair within, , 200-ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION TOWN TM # OWNER'S NAME. R17.6 el? r SAP? PHONE# MAILING -ADDRESS pfdjga h0Z P- APPLICANT Name& Relationship (i.e., owner, tenant, DATE FACILITY TYPE --PCHD COMPLAINT# PROPOSED INSTALLER PHO! NE# ADDRESS REGISTRATION /LICENSE Proposal (include a aep4ate 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.. 4 10, as owner,agree to the conditions stated on this form -SIGNATURE 6a:e&4,?e- TITLE pZ,„ ®„ DATE (owner) 1, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE 14 DATE (installer) Proposal approved with the following conditions: A. 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 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. A I a 1^ P%Ikll %I - In I Mrs"PU- Proposal Approved Proposal Denied ❑ Ile, Inspector's Signature & Title Date Expkatio6 Date ,Repair proposal is in compliance -with applicable codes Yes No 0 COPIES: PCHD; Owner; Installer PC-RP 99ML Rev. 2/07 dee,60416wo )PIACe "tic- T #NK box 0 AAt; OC7�- Cor- / VWX air a 14-7 TA144 76. TAt*—Py"�,v '6 T" 1 :26 19,rd 7y ® ^tea vi �� m t a Is a a �6_ A>. ® y139d .1; �i dON�'J. N 1- � t7J• Z. Qd ��0 � � � � �. •Y8� ` �' �`h�r2 ��b � � �, w 3 w a ! Y' °� s•• axF. x7 t r �. - ` �"' K+. � +a yw > "y } O'{�" is �. "y. - 4 'v ra•R�c x �. -t �` "�4, 1i'r ����11�,' � � ',,���«� �� - �� � �1 �3��Oy7 'tom'• � °�'�` w,�. `ka� 'r� ��'� � . *y ?�,� �'G� bn�,4��� �:x.'� �:��;r ' y��..._ -v �,�a.g � °X� c�Y � `t may' .. �+¢. �.��� � i���,'���+'�e��� " s �,� i c t�. � 1�;�v�'{ff•�' ,g, a F `tfi f o bn2 cl t c... .� /Qkl1 r : yi"- ��`a �c; ✓s� .o+" $�t�,�'. 1 Z} Q 5� ' . ! d1 Atl�!1t1 0 y �a 3 � p•:^ J W ZQ #� i h0 O ' w fi ✓ ,� � zy Oaa p � 91 y31 j O O m� QV Q tS Z o t, dkl C, t S3lc .l r 1 y J 1z f Q N3U O� 3 c¢ a JN(10A U ViN3x u S31VA seal C O/yy. N ..... -. �_ ......��:__._�.....:_� �� 1. , .... . fvu Vi �J � Q nr � d § ti I vi --------------- x 4 1 Re-D woQD PL ce DtVo---v-, - -,, - i Reow i0Oa ®/ocp— J�Ijl -a -ado PUTNAM COUNTY DEPARTMENT OF HEALTH DIMION.OF ENVIRONMENTAL HEALTH SERVICES DESIGN. DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM owner: SW�i� In Adds;: l lZet/wo ©c� , f�lace Located at (street) TM # Section: _ Block _ Lot Niunidpality: �d e�S ®b1 Watecsltied: '19�5aS+- braIncL, SOIL PERCOLATION TEST DATA Witnessed by: zed Date of Pm4oaktat: 1013113 Date of Pereoledn Test: Hole No. l ttn No. Time Start — Stop .. Elapse Tim Thine ( �) Depth to water from , rooud g s�ur�%ac�e, Start = Stop Water ' level drop is inches Percolation R kte min inch 1 0 9 —10,3 — ;to. 3/y 3 � . 1 30 3 hfavy - 30 i r Z 4 . i . 1 3 . 4 S I 1 3 4 3. l . 1. . 3 4 3 . Notes: t. Tats tobe repeated at some depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., c t min for 1 -30 min/inch, < 1 min for '31-60 min/inch), All data to be submitted for review. 1. Depth measurements to be matte from top of hole. Form DD -97. Poor'? TEST PTT DATA , DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH ' "HOLE #� ` HOLE # a� . FjOLE # HOLE # -T " HOLE # V.L. • 0.5' . 1.5' Sa. • 2.0' 2.5' 3.0' 3.5 4.0' CT a T:5' a.0' _ Indicate level .at which groundwater is encountered Indicate level at which mottling is observed indicate level to which Yam level rises after being encountered Deep hole. observations made by: Date io -7 A3 Design Professional Name: Address: Signature: Design Professional - Seal