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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
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Scale Y4"=
DC8s 1
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110
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DC8s 1
Notes
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•
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