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BOX 18
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02092
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT )U i
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use Only PERMIT #
Repair Permit issued in last 5 years LJ /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 ❑ Joint Review
J t
DATE o�-Itq-e FACILITY TYPE &rile- PCHD COMPLAINT #
PROPOSED INSTALLER J -0tit5 G ��' c•ir- j PHONE # e%r .PS7''3S`73
ADDRESS . S � REGISTRATION /LICENSE # gGI l
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. /
A'Ai . / rat I t (
I, as owner,agree to the conditions stated on this form
SIGNATUR E TITLE DATE
(owner)
I, the- septic-instailer, agree to comply with-the conditions of this permit for the septic system repair
SIGNATURE ,may 4v44' TITLE __PXA//'J' DATE 49 � -/y 0 ?
(installer)
Proposal appro d with the f lowing conditions: t
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
Pro osal App - Proposal Denied ❑
I /Q dJ-Oi 12-�Cjcf
Z eDpector's Sig ature & Title �n Date Expira ion Date
air proposal is in compliance with applicable codes Yes ❑ No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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PUTNAM COUNTY DEPARTMENT OF HEALTH`
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner:
Located at (street):'
Municipality:
Address:
TM # Section:— Block— Lot
Watershed:�,.f z �.
SOIL PERCOLATION TEST DATA
Witnessed by:. , 0 1'k
Date of Pre - soaking: 62 J 4 Date of Percolation Test: y `,
Hole No.
Run No.
Time
Start —
Stop
Elapse
Time
(min.),
Depth to
Water from
Found
surface
(inches)
Start - Stop
Water
level drop
in inches
Percolation
Rate
min /inch
3
pv- -
a-
4
5
'
2
3
4
5
1
2
3
4
5
1
2
3
4
5
I
i
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.
TEST PIT DA A
I ''SC'RII "I'ION M` SOILS ENCOUNTE'RLIA) IN "I'1. �'l IiOLI S
DEPTH HOLE r '�/� HOLE # HOLE a HOLE P HOLE
G.L.
.0'
1.5' fill
2.0' �1
2.5
3.5'
4.0.'
5.0
5.5' �,-
6.0'
6.5'
7.0'
7.5'
8.5,.
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:.
Signature:
Design Professional = Seal .