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HomeMy WebLinkAbout2209DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41. -2 -24 BOX 19 a 11 I ro .. 1A`1- - „ fill I .)I ' , q, , r L a ■ ■`, IN* 1 ' �� : N , ' ' qr I I I rl Lm a 02209 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0 a FOR- SEWAGE TREATMEN�.SY�TEM,.REPAIR .. .. .» . i c' YE NO / ' Internal Use Only PER�NIT *V !n -O�v u ❑/ LAS ❑ Repair Permit Issued In lest 5 years Repair within Boyd's Comers, W. Branch or Croton Falls Res. Repair within ft. f a watercourse or DEC ;mapped wetland LV ❑ ❑ Not in Watershed Delegated Joint Review SITE LOCATION 4 �, ,TOWN '?—Ls I f TM # , - zr' OWNER'S NAME <, PHONE # MAILING ADDRESS JAJve APPLICANT erne & Relationship (i.e., owner, tenant, contractor) DATE r FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER u.' SNu, J C. _ PHONE # -' 9041, U� ADDRESS REGISTRATION /LICENSE # 11 Pro sal (Include a separateiketch 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 tthe repair. I, as owner,agree to the co iti ns stated on this form V SIGNATURE I TITLE DATE (owner) _ .... . I_, v le se ptlC'IrSta1 2P, a g r corn i 'th conditions of this -permit -forthe-septic systom repair-° _.a.... J .. SIGNATURE TITLE DATE " (Installer) Proposal approved with the following conditions: 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 backfillep until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pro Gsal D 13d Date in compliance with aDplicable codes COPIES: PCHD; Owner; Installer PC -RP 99ML, , 1 9 Ex0iration Date Yes No O (� ]] R 2/07 Y fio� u (A•�t �� 56"' _ Scale Y4"= DC8s 1 Notes qqvt Q 4f milli 110 NOON mom mom mm DC8s 1 Notes qqvt Q 4f DC8s 1 ...wn .:.. uQ.+y. ...._�.. i.r r.. _.�.0 .r h.... _ -fir S• _ n.s.. r.�_xw... r... J... J. ..c..�.. _. �.ta ..... _.. ... v r .i ...a ..•. n._.. ...... .. yt.... ���. • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information mast bed completed prior to any scheduling. Date: Engineer or Firm: Phone #: 9& 0 f Person to Contact: ' E? ❑ New Construction Reason: O"Deeps ❑ Repair Program 9+eres 11 Pump Test Road/Street: - 5 fJ j A / Town: Snbdivkinn- Owner: ❑ Addition Program Tax Map #• T nt #• ❑ .Project not within NYC Watershed NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL- TESTLVG - _._ _�...._..._ ....' 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. ❑ ❑ 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 yes 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 oil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: TIME: COMMENTS: Req.for field testAly 4/16/2009 r sa t PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREAT`vli ENT SYSTEM Owner: ad & Ice '' Located at (street). er< eJ Lct /lq— Municipality: Knan^ Lt. Ikv Address: JS Sit4rA' LaAe •1 M7 9 Section: �L Block Lot 2— T Watershed: SOIL PERCOLATION TEST DATA /✓ J/� • ,, / Witnessed 6y: Date of Pre - soaking: Date of Percolation Test: Hole No. Run Rio. 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 2 4 J . I 2 3 4 I � 2 3 4 I 3 4 Notes: 1. Tests to be repeared at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < t 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. TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES .._., � .._ .... o-.. �..: ,...- .> 'r.. -...s •- : vu. _. �.:. e...,. ,.., v = ,va, o,. ,.. _ ..� .. .-c - -.._.. _ ...... _•, . 'm- .•� -s.. -• +s rr.n.. r..Y�.i -a.. . . DEPTH HOLE # HOLE # HOLE # HOLE # HOLE #^ G. L. S. 0.5' 1.0' 6�wc 2.0' 2.5' f�l o 52t' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 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: A `D (� Date 2 ( l Design Professional Name: Address: S i pature: Design Professional = Seal