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02154
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
T
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YES NO Internal Use Only PERMIT #
❑ V Repair Permit issued in last 5 years VDelegated
ot in Watershed
❑ . Repair within Boyd's Corners, W. Branch or Croton Falls Res.
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION TOWN
TM # _�? 0. „-2 - V.9
OWNER'S NAME (rte is prc � . Pa r e Z, PHONE # /- y17 • s7A$=
MAILING ADDRESS �/ Qr.4,.�,,, S ��+�- c,/Zf �•�
APPLICANT e A �-�^� .i r • L
Name & Relationship (i.e., owner, tenariCconlraclK
DATE -/- U-7 FACILITY TYPE `3 PCHD COMPLAINT #
PROPOSED INSTALLER jq,� PHONE # 7060 �iy 7
ADDRESS �cJl REGISTRATION /LICENSE # AjY •-- O/
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.
C A-Gfz» Sc�.o'�•� T/ -a�yl c= �c� �-i9� �i Ct9 r'L /C2s0 �j.� Lt. i ^� i'�� �tS�A n/
I, as owner,agree to the conditions stated on this form
SIGNATURE _��, !� TITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE -A,� TITLE �•^c-5 DATE 37'f"
i t II
(ns a er)
Proposal approved with the following 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.
INTERNAL USE ONLY
Proposal Approved ❑ Proposal Denied ❑
4.). ef:e',� e�,4, !� �
Inspector's Signa ure & Ile Dad Expiration Date
Repair proposal is in compliance with applicable codes Yes O No
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST DOLES
DEPTH HOLE #__L_ HOLE # HOLE # HOLE #. HOLE #
G. L.
0.5'
1.0' fi% owl
-
2.0'
.2.5'
3 0' S;' 4Q /a
3.5'. ti/ r/116
4.0' cr.
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
9.0'
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
Dee
phole observations made by: ,!!�r �/ �7. Date t 0 9
Design Professional Name:
Address:
Sicynature:
Design Professional = Seal
tz
N
t
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
REQUEST FOR FIELD TESTING
All information must be ll completed prior to any scheduling.
Engineer or Firm: ,Led ApAmS ��' -�✓�' c
Person to Contact: �� c( l ?
Date:
Phone #:
❑ New Construction ❑ Repair.Program ❑ Addition Program
Reason: ,!J Deeps . krPeres ❑ Pump Test
Road /Street:
Town:— -- - ' Tax Map' #: <30,
Subdivision: Lot #:
Owner: ( POST � �L i2 �'2_
❑ Project not within NYC Watershed.
NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING
YES NO
❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner
reservoirs.
❑ ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
El. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required.
❑ ❑ Proposed SSTS for a Commercial Project
It is .the responsibility of the design professional to provide the above information prior to soil testing.
This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. '
If you answered vs to any of the questions, NYCDEP must witness the soil tests. This Department will
coordinate 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 CO.UNTY'USE•ONLY
DATE: 5 TIME:' 3 L 3O
COMMENT
Req.for field test:kly 4/16/2009
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLII SERVICES
FIELD ACTIVITY REPORT
NAME Tel:
„nr)RFce; oEll' 7?iy -DplA9G ST, �uTiU14!►? j%f�GLL,`r /J�i;
Street Town State Zip
PERSON IN CHARGE
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Name and Title
TYPE OF FACILITY: T S
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FINDINGS:
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Signature and Title
RFPQRT RFCFTVFT) BY:
I acknowledge receipt of this report: SIGNATURE;
02/96
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As Built For: A 1q p t&pp r -v1 S4—• P "* U &t1&1
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Fred Adams, Jr. Inc.
691 Farmers Mills Rd.
Carmel, New York 10512
(845- 225 -8123)
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Fred Adams, Jr. Inc.
691 Farmers Mills Rd.
Carmel, New York 10512
(845- 225 -8123)
97-/4-09
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