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HomeMy WebLinkAbout2353DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.14 -1 -21 BOX 20 ME I I,y96 T r L ' a`l.r mi `.. elm 1 r N' ,� ' r� . om 02353 PUTNAM COUNTY HEALTH DEPARTMENT C Q DIVISION OF ENVIRONMENTAL HEALTH SERVIC / PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR 4 ., �� ✓ YES ; NO t Internal Use Onl „ ' PERMIT # , ,,` , D Yt ❑ IJ Repair Permit issued in last 5 years FI 15ot in Watershed ❑l / ®--' Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated L ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT DATE 6 C* 14-6 hf c- TM # i-I I - 1' Z NE # f'fV ,�"�LZ 7J (a ®r� i 0 M ! I Ut Name & Relationship (Le., owner, tenant, contractor) FACILITY /TYPE si,.'.��M PCHD COMPLAINT # PROPOSED INSTALLER �•'� ` G VV �fJn�IS � PHONE # �`�� 6� D �-3.3 ADDRESS 3 Zv LnI�, P-$A-,KSW %Iy REGISTRATION /LICENSE # /0 3 P 37,✓�- 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)ltJ NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of th r pair. L / �+ I, as owner,agree to the conditions stated on this form SIGNATURE �«�� —�jZ- ,y�i'7 TITLE Ow'�16F O\� DATE 1'1129 I3 (owner) the-septic- installer; agree to compl with the conditions .of this permit -for the septic.ss /stern repair - SIGNATU TITLE 01_--� DATE (installer) Proposal aRRroved 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 Pro os jai A p v d M Proposal Dented Ii T -110 .. �t � 2 In pe or's Signe ure & Title D to Exp ration D to Re air proposal is in compliance with applicable codes Yes a- No O COPIES :� ';.;. PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site Inspection t Date: 3� �� Inspected by: _�_ Installer: Loci ..Street Location- Sfz o � Owner: �y,�nsvn /A 1->huo _.. _. _ 3 K .Town: . � 'aM Q Re au Permit #: - R.U`t� -13 TM # 1. Type of System: Conventional ❑ Alternate liKomments:. �' ��� �I er I) L s kDo 2. Septic Tank Yes No N/A Comments a. Septic tank size — 1,000 ... 1,250 ... other ..... b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. Distribution Box i. All outlets at same elevation (water tested) ... : V101 ii. Protected below frost ...................... :...... iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box — properly set ........................... f. Trenches i. System. completely opened for inspection ✓ ii. Length required Vii_ Length installed I ±L vn iii. Pipe slope checked ... ............................... iv. Installed according to plan ..................... Vol v. 10 ft. from property line — 20 ft — foundations 1/ vi. Size of gravel ' /< - 1 '/1 " diameter clean ......... / V vii. Depth of gravel in trench 12" minimum ......... viii. Ends capped .... ............................... g. Pump 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 Workmanship, 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 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 F I LE Nll�dBER DATE ', 'APR—:29' 02:52PM '{ TO 85280781 W. DOCUMENT PAGES 001 ' .. STAPT TIME APR -29 02:52PM .:,,END TIHIF_ APR- 29.02:52PIA SENT PiLI'tE , :' 001 ' FIIE;NUMRER 934 �' 'S.IUCCk :SSFUL: TY NOT I CE * ** >F'LJ IiA, 66brj "f'I' F -0EALTI -� G EPAFi i'MENT I?0 \/I IQh9 01== EIVVIFtC >t JIPNEf�(TAI_ '=AL-M 1 SEF2VIG� i '� j -Imor c' — L IFS S�S� !�.:1= 'T�t��4TM w-r S-qP!STEM StE:_FDAiR ' r�rnte+rttaf usto tJrlav p'ERfNier 8 -- D Y8"-- / � fPissr, Parrrf t 101 --a in MMr. is ye. u•s Ot in WatCrShad f �J r : (i�~� 17uPWr wnh(n BOYa7o Coi,yaic: Vv. EimvrefYOr Crown r =ells Flos. 'ice Oei10gat60 .. L .C•��^ ... - O RffpN _witn9n'20(f iR aT a wa'Rmrzf :lrsm or P�GnrapP �d wntlaritl CJ Joint RaVIQW `l ",!SITE Q:C71:.A -f"ION '::r. S' �:(p, Gi+'�5'A.+D't�_" ..•... - °-._- WN•w_T� /.:aw•�' ✓�- �d:� "` T'N!' #'.. .,� � J ?...`- OWNEKi'S NAME- a%rJ ©r( rl /_�7 Al •, MAILJJVIG .A!?ORESS , ' :S: G -. � -..S I:. S: a_ sAs L L APPLIcAh1Y' �r'q -✓ ♦'�.__•r�' �.6Z ...�s._ . Nlslrno dL RelwzlO 't:hlp 4i o . e Swl ItOrfent. contractor, ,L / i .DATE �.'7 T"'�'�/ �} ,Y_ ' . � FfaCC CITY -i' Y'PF- �_�':!� PGHO COMPLAINT q PFIOPC'ti l_:0 INS- TALLER �:r'r��w -/'' :G �� :C•�r.�..:i!:yJ' p -_— PHONE # -r V M 6 /. o --S �r-� _ _AO��E .`_ _:, 3' "'`%..�ci� _G.arI L:I.I�.;�"�- .'- rx�'•S�'Qi _,%!+(�.. Ftc23tu "'FIATI tW %LICENSE Ar /0�3 "' r'• �� •9ds -, Prc.cfonni (Incrutl® at >parutl�atcatcztt 1tacaSin}� tOtm ho�0utse, Pro+pefrl ;,r fines,. atr adjactat-rt wafts wltVttr. 200' ..743at oR tretpair rbnd the la awti•an eit feileftl:tir„g mmKa pi-c-.posad. systam;I ii NOTE' : Thred a artmemt'rria r . -- - •� •����- �' ',�•. P Y., aqulrt3�s:.ibmit¢al'�of Kiropctsal�from .iioe.nseO.profassionai d�epanding -on ih8 `:�• -' .~ ' Wit- ' . rtatijreB, and oxtanr of th �t� - .. - -�� .. -. ../'.�w.:e._9 �+ .- r.s•z��,.�..rrl...:�':_.�.c.e 1. - .. '.' t a- 4:ouvne ,Eig'ro® t6.81•ia oonditieiJn //��_tntr d do th l3Yonr1 L� SIC N^T *;; l iE= .f=��6 G S....�- r<�c�cac x<-_°' _ TITLE O���r� !? 6P OATE 4tZ!! (ow ntfirD � t, thEi s:epl4c inStallal ssgraa to corn ply % ith thoa concillions of this Iperr iit for thief saptic systant repair LE... . Pi1i121�Hill3i6•nrovlod with thrs foil i3rr6d manditip�g� _ - ,7 PmOtnr meant of say Tcawrr PermK..lf rapt illcabl:o ' .. .. lae tonof'as builtrapiziiraiketch.tly! rhea,sepl3c;sydtfam:ineslallar ; vvlthlrt 3p dayseof. ttia repair;;.iri_duplieata6howing:;. .. , .. a: (anrnier's rioma. Bite Btraat Nary e . Town ancs Tax Map numbar b_ Lea.:etdon of inwtmllad componentta tied to ry fizaf.l r�lnts c ,FSyettRarr .dersorlpe:orn,(a.,t t -. t2SO :g4a1_ (� oacnrat6. emepts.a tank. entO.) . d. Gnstnilar5' nsmae'aand ptfono.nurttlSar 3 [sy6Li eef,l repair t0 ben p,errcarinfta 1,*mc.eor :lamoe — th tk— ulz oya Proposal ."Cl I —dldo ., 4 . t'ttt ise-sign and h u tere Is :ro g imtea to the duration at whic fi h ve comapl6fne•d SETS repair yAll furiction_' Nc> c:o-IZplartmcl vvdrk [a to tso btneknlbed t ntil mutl'lcrt vwl irte't to do so has Paaen obtained from the O©paitrrtetnt_ _ eV rTBSI t -I/ � Uffit_' ONLY _ Pro oti�l >I )��p 'I- rrposml Of9itl 6cl it'al • 1`c t j 1 1: � Y•t'signa. ra'..K. ritfr = >; O ta.,.. Exp ratinO to in I3 stir iai r easel is c nin�limnao w1(t IQIjreA,l3j•Pist �,^ (a o . - COPIESPCHO: Ownedr Instal bar PC Rh, fJ i! tL.' i ' 9' ' . .. Raw. 2/07 .. , , -t L� �et vcy PU'TNA�M COUNTY DEPARTMENT OF HEALTH DfVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM i caner: o�it sei/ 0 Address: G LeaKe jAvr4 Dr. Located at (street):I j TM # Section:' ^Bloc[( Lot Municipality: �T �4M o� � I e� Watershed: SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: Date of Percolation Test: Hole No.. Run Nl o. Time Start - Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop Water bevel drop in inches Percolation Rate min /inch ..2 3 r_. I , 2 3 4 1 � j 2 ( - 3 I I 4 f 4 1 � 3 , 4 Notes: 1. Tesrs to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test. hole. (i.e:, _< 1 min for 1-30 min/inch, < ? min for 31-60 min %inch). All data to be submitted for review. u 2. Depth measurements to be made from top of hole. Fonn DD -97, p�l : or TEST PIT DATA Indicate level at which groundwater is encountered lean e Indicate level at which mottling is observed AL e / Indicate level to which water level rises after being encountered 14 Deep hole observations made by: M ®L Date 24 13 Design Professional Name: Address: Sipature: - Design Professional = Seal DESCRIPTION OF SODS ENCOUNTERED IN TEST HOLES DEPTH HOLE # HOLE #_ HOLE # HOLE'# HOLE # ` G. L. 1.0' 2.0' 2.5 3.0' un� 3.5' 4.0' a 4.5' uryn S nts 5.5' 6.0' -6.5' ., 7.0' . 8.0' - 9.0' 10.0' Indicate level at which groundwater is encountered lean e Indicate level at which mottling is observed AL e / Indicate level to which water level rises after being encountered 14 Deep hole observations made by: M ®L Date 24 13 Design Professional Name: Address: Sipature: - Design Professional = Seal