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HomeMy WebLinkAbout2323DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyQurdocs.com 631- 589 -8100 41.10 -2 -40 BOX 20 02323 1 Y : � N' ' �r �1 I . 1 ' I Jam♦ Mme' lir T ' 02323 PUTNAM COUNTY HEALTH DEPARTMENT ►/ DIVISION OF ENVIRONMENTAL HEALTH SERVICE r PROPOSAL FOR SEWAGE TREATMENT SYSTEM REP )MR _--/ YES NO Internal Use Only PERMIT ❑ Q/ Repair Permit issued in last 5 years © Not in Watersh@d ❑ �� Repair within Boyd's Comers, W. Branch or Croton Falls Res. y❑r Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION 4-9' A, R8g:ole / ey 4-1-10-2--+0 OWNER'S NAME &ELL1t,1Gti4AM PHONE #L345 2- MAILING ADDRESS os ® 1✓I ALL O APPLICANT F Qei R)P_Li_I A PA S Name & Relationship (i.e., owner, tenant, contractor) DATE 011(0112, FACILITY TYPE �11 PCHD COMPLAINT # PROPOSED INSTALLER Piz�ELLA [�;, -.L-t- G- - PHONE # 15!L %3q— ajQ -,�5 ADDRESS 7 DQawaan2l Co REGISTRATION /LICENSE # 1 Q8 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. _ _ I I, as owner,agree to the conditions stated 0 1 this form SIGNATURE 4 Z ITL ` DATEQ� (owner) - I,-the se ptiq'instailer; agree to c ply with t e conditions of this ermit for the septic system repair. SIGNATURE TITLE DATE Z (installer) Piz L (LO vTNG, Pr000sal a ro 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 backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Q Proposal Denied ❑ 01 A3 Inspector's Signature & Title Da e / Ex ' ation bate ,Repair proposal is in compliance with applicable codes Yes Cad No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 f / RALPH G, MASTROMONACO, P,E,, P.C. .` Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 (914) 271 -4762 (914) 271 -2820 Fax Mr. Gene D. Reed Senior Engineering Aide Putnam County Department of Health Environmental Health Services 1 Geneva Road Brewster, N.Y. 10509 Re: Proposed "Best Fit" Septic Repair 49 Arbutus Road Town of Putnam Valley, N.Y. 10579 (T. M. # 41.10 -2 -40) Dear Gene: Enclosed please find the following materials: September 10, 2012 1. Three (3) signed and sealed copies of the following drawing: a. Septic Repair Plan (Tax Map Data 41.10 -2-40) Located at 49 Arbutus Road, Town of Putnam Valley, NY, Prepared for Gerry Bellingham, dated August 8, 2012, 2. One (1) signed copy of the Sewage Treatment System Repair application, 3. One (1) postal money order #20256610162 payable to the PCDH in amount of $150, We are requesting your continued review and approval of the submitted materials. If you have any questions, please do not hesitate to call me. Ralph G. Mastromonaco Cc: Bellingham w/ enclosures RE c r,rIVED 9 PU TNA I C 0 UNITY DEPART -MENT OF HEALTH DItiZSION OF ENTVIRONNMENTAI HEALTH SERVICES DES 1G1q DATA SFIET — SUBSURFACE Sri-WAGE TREAT�MENITT S --J/STEM .-B - da dA A -/,? �-izoxD Owner: t--- address: vo Locited at (street): TIM M" Section: 8 10 Ck- Lo-t jVfuriic ip a I icy: —Py-rAlAA VA 4 L, C— Watershed /k!) SOIL PERCOLATION TEST DATA Witnessed by: D a te'o I Pre-5oa king: Date of Percolation Te.s,t:..--, Hole No. Run o. Time Start— Stop Elapse Time (m in.) Depth to water from Found surface (inches.) -Start-stop );Vater level drop ill inches Percolation Rate min/inch .3 .4 2 3 3 4 4 Noes: 1 T-cc. r rn ip ir a rienrl) 11rr:1 0u1-02 -12 OS:1SA Ralph Mastromonaco PEPC (S14 271 2820 P -02 i 577 .. • ............ Cl LOT � v L�9G i i sro.cTy � ti ' o w�'c.c �iVG 0 �; o Tucc o C O � WELL /NG a? �w►y r Jos- 1 o Q � —9710, 54G 0.00, ovol Jul -02 -12 09 :15A Ralph Mastromonaco PEPC SHERLITA AMLER, MD, MS, FAAP ... Conrri:&sioner of He&1tlr - _..... LORETTA MOLINARI, RN, MSN Associate Commissioner of Health 914 271 2820 P.01 8 4-5- V - -7921 ATr4- Gasp WaW ROBERT3. BOND[ 'County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTING All information below must be fully completed prior to any scheduling. DATE: -Z Z. ENGINEERING FIRM: A5TRoH ACO CASOGT PHONE #: 914--50&-038 -7 10 EARS PERSON TO CONTACT:-H.1 k,G' I%L-U: ❑ NEW CONSTRUCTION ^REPAIR PROGRAM ❑ ADDITION PROGRAM REASON: DEEPS: A PERCS: Y PUMP TEST: ❑ ROAD /STREET: 4- I A N gLmo— s QOA M_ TOWN: POT- Am TAX MAP #:41. Q— 2 -40 SUBDIVISION: ROAR A6 BROOK- LOT #: OWN`E R:.aJ? P,Y bE LL' Ii CadAM - - NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SO[L TESTING YES NO- ❑ X O ❑ X Proposed SSTS within the drainage basin of West Branch or Boyds Corner & Croton Falls 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 2000 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. The Department wilf 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 Professional and NYDCEP. 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 COUNTY USE ONLY DATE- 2 TIME: COMMENTS: Rev FOR ern 1)TUIMNC Ku Environmental Health (845) 278.6130 Fax (845) 278.7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early intervention/Prewhoni (R44)77R -AO14 FAY (Rdtl 77"Kda Slice t of PUTNAM COUNTY DEPARTMENT OF HEALTH _... , DIVISION OF ENVIRONMEN,TAAL.HEATLH SERVICES.- FIELD ACTIVITY REPORT NAME: pp Tel: Street Town Sate Zip PERSON IN CHARGE ,r� OR TNTFR VTRWFT)-. Data; ll` /la Name and. Title' TYPE OF FACfiLITY : r_ JCa amt .% i 4L24 . !q 15, FIN INGS- �jZ -�vv ' P al; vtif S .slave Per _ � 5 �n 6 TN4PF.C`TQR: Signature and Title RFPQRT RFC:FTVRD RV: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: Rev. !.m- `_ i f 6 TN4PF.C`TQR: Signature and Title RFPQRT RFC:FTVRD RV: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: Rev. CD �OERICK LA OSSR K OR 3 OVICCOPEE .......... �Y, i D ndO 7f Nut A ABU C & 0 PUDDING ........ . ...... . . .. . ........ r tic feu o NOOVOID t% APPROVED BY- . - - - , ',.DRAWN BY: Act A'A P v'r v c1 Pat IV tai ° � t DRAWING NUMBER: {i i Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Final Site Inspec ion Date: to �/ Kell 3 Inspected-by: G , Installer: T 114 Location: _ c�-y5 : ?dt, _Own_er: ��dff✓14:1n �,v� �:.:. „ �......... < Town: Pyj-vi a-wt Vaf l e-V Repair Permit #: - 19 G -1.'L TM # 4(/, /D - p 1. Type of System: Conventional 0 Alternate 0 Comments: 2. Septic Tank Yes o N/A Comments a. Septic tank size - 1,000.... 1,250... other ..... ���0 U 5e 0,149;61 d (, Pirvpos sI� mat iasfa -I(e� dotes keg b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. Distribution Box i. All outlets at same elevation (water tested) ... 4 j, d /­w ,-o U 3� s� S .e - as re�tcb 4 . o � r ow ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box - pro erl set ........................... f. Trenches i. Systetricompletely opened for inspection ii. Length required t� Q Length installed iii. Pie slope checked ... ............................... a c11 S ni iv. Installed according to plan ..................... o� - ik d v. 10 ft. from property line - 20 ft - foundations ... •/ ow'cale. s in—1 aw 15,w4e w �t 8 5T5 . vi. Size of gravel' /. - 1 '/2 " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... viii. Ends capped .... ............................... R. Pumv or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per a roved plans b. Fill section - c. Distance from water course /wetlands 4. Overall Workmanshipo a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box ......................... c. Backfill material contains stones <4" diameter ......... d. Curtain drain & standpipes installed according to plan l e. Curtain drain outfall protected & dir to exist watercourse f. Footing drains discharge away from SSTS area ......... g. Erosion control provided ............................ Additional Comments: RFSI Rev - 011312 PVC 3a DT� O7L MIN. 14.5,_ L1 — I \ ARAGE I L3 I \ \ a L4��- \ 10' MIN EX. DRIVEWAY TO P.L., I I I S 41'56'00' E 97.10' I I LINE OF SILT FENCE I I F I AP�?BUTUS EX RET APPROX. LOCATION WALL . • EXISTING WELL PIT PATIO � i o r a EXISTING 7W0 (p) 3 BEDROOM DWELLING EXISTING DWEWNG $ V I: APPROX. DW'ELUNG EXIST. 7 50 GAL. PR. 1000 GAL. aO SEPTIC TANK TO HDPE PLASTIC N ABANDONED SEPTIC TANK BE AB PER PC DH RULES (FRALO BRAND) WELL PIT EX. 4' CIP 1p• MIN. SEWER 70 TANK PATIO 3 I a 70 IF S a \\ PPS - PR. CAP \ ti m 0 CLEANOUTED _ �m1' PPZ afP PR. 20.0 LF. \\ EX. DRIVEWAY X 3 6� 4' PVC SDR35 S - -2-OX MI N. 7Q i1 w - 68 PR. L.F. \ \\ 7Q P EX. SSDA 4' SOLID PVC SOLD MIN. \ -p UNKNOWN SSDS TO BE Q \ vi ABANDONED Y DB � \ OUTLET PIPES \ SOLID 866 4' SO I APPROXIMATE \ LOCATION OF EXIST. SSDA I \ 3 EXISTING PHB G PVC 3a DT� O7L MIN. 14.5,_ L1 — I \ ARAGE I L3 I \ \ a L4��- \ 10' MIN EX. DRIVEWAY TO P.L., I I I S 41'56'00' E 97.10' I I LINE OF SILT FENCE I I F I AP�?BUTUS �7. ST2EET n .1. 1 4 APPROX. LOCATION EXISTING WELL t i i� . I ( i PATID u APPROX. LOCATION EXISTING WELL PIT EXISTING EXISTING I: APPROX. DW'ELUNG GARAGE LOCATION EXISTING WELL PIT y PATIO \� PCT \ —870 EX. DRIVEWAY \ ��y 1D0 \ I \ n;r SSDA 7,000 s. J. 1,0 968 HA I tl - 10' 866 APPROXIMATE OAK — MIN. LOCATION OF I EXIST. SSDA 5 I. � — 856 —964 - MIN. G PR. 2' R.O.B. FILL OVER SSDA I -864 / I I / I I 662 -T. WALL �7. ST2EET n .1. 1 4 APPROX. LOCATION EXISTING WELL t i i� . I (