HomeMy WebLinkAbout2106DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.57 -1 -11
BOX 18
02106
I'
.'`
1 �1r
�1!
'
.
.
.
is . IF
I-
I
I
II' . �. %
k
6' '.
.,
I
I
ls I
I
Ij -
`
I.
ow
IN
02106
�= 'l 3 _6%67T Pal
DIVISION OF ENVIRONMENTAL HEALTH SERVICE:`
AW
PROPOSAL FOR j0LAGE TRZA MM REPAIR
A_
__0 RW* Penn* b$U8d1n last 6Y&sfv LJ� in WaWshed
❑ Rop&wMftBoyftC4rnm,W.BmohorCrMnFOsPm.- Id. Delegated
❑ C Pop& w" 2W C d mmWomm or DEC-MspW;6WW ❑ Joint RGVi8W
r< v
SITE LOCATION 11 'Kvq:5t K s� TOWN fly N_(A TM # 7 1
OWNER'S NAME �Zo 114 LPt C C ,fin L,1 PHONE # C117 -2-
ios-vq
MAILING ADDRESS > -sys-r -
APPUCANT
DATE
PROPOSED
ADDRESS
IWIMN=WAMIN
Mmm & RWWWndgp PA.. wmm. to cWfts0W
FACILITY TYPE P-,c 5 PCHD COMPLAINT #
R
L f,
E PHONE#
654ff I,- i+ x
_f,if+k VAL LE. yjAj.j0S_"F'1 REGISTRATION /UCENSE # 10!e
-.3
Prop-p-sA31 (Include a separate sketch locating the house, prop" lines, allli*cent wells within 200
fed of repair and the location of ed0bg and proposed "stein)
NOTE: The Department may require submittal of proposal from-licensed professional depending on the
nfth era anti awl ant of tha ramir
t5v --
Y%>
1. as owner agree to the conditions stated an this form
SIGNATURE
1 TITLE QQM W(\_ DATE. fLZZk1d 5--
(owner) I f
1, the septic 1SWPr, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE4A, TITI-E DATE,
ftMW aRRamW with the follouving =dIllow,
1. Procurement of any Tom Penn[L it ai*ua6w.
2. Subwdesion of as buft repair sketch by the s"No system Installer within 30 days at the repair, in duplicate show!W.
a. Owners narne, Site St rest Name, Town and Tax Wimp number
'b. Loc"on of Installed conVanents tied to two fund points
c. System clescription, (&g.. 1250 9W. Concrete septic bwdr, etc.)
d. InstWeW name and phone runber
3. System repair to be performed In accordance whh the a6ave pmposW mW cioncutions
4. lire proposed SSTS repair- is considered a-bad fit design and there is no quarantee to the•duradon at which the
wmpkftd SSTS repair wWAmcdcn.
5. No completed work Is to be bad W
'led until auftrization to do so has been obtained from the DspamnervL
Proposal Denied
is in
COPIES: PCHD; Owner, Installer
PC-RP .99ML
0
Date'
Yes 0
No
Rev. 2107
q
d
�a
r
�!
k
t'
f�
�F
�
�
J
,2
M1
OL
r
J
l
VV- f16
I jet pt
7r" --1
�5 zb
ek-
PA
" e '
IteP`r • t,( -r- K
r�
E3
TR
Cn
..................
Wl
-;0*7 -09)
"7
/S XSA(,Sf)YrO'j-Oty RA
o ae vu �g
7'-6(A-IH
(/61 A
R4
00
VI(-
-3
\AJ�6P-Au V-
#SF,
w
IVOCGOA-L-
--rA � -
cvo�a?-OT►�
,3 ,
1
_n
k
,
r
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner:
Located at (street): ��(er•,S: k'�
Municipality:
Address: !0 l�ev�>w�`S�„" /t,4
x'6,57 / c
TM # Section: Block Lot _
Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by: -J� ,,J,
Date of Pre - soaking: 1 5/ i 'I Date of Percolation Test: _ / � �, /�> ci
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
21
1
L0�5- i:`;5S
30
q- 1-71 U-T
/
30
Z
4
5
1
2
3
4
5
•
1
2
3
4
5
2
3
4
Notes:
1. Tests to 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 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 t of 2
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE #_21 HOLE #
G. L.
0.5'
n -'S -71
1.01
1.51
Mad
2.0'
rVLA- Sd j ji-A-4)
2.5'
3.0'
3.5'
4.0'
4.5'
cji&A
5. 0,
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.5'
10.01
HOLE # HOLE # HOLE #.
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered
-D /w ilf
Deep hole observations made by: -1. � U 1, n, CA 4 Date
Design Professional Name:.
Address:
Signature:
Design Professional = Seal