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02503
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH ,/ n
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DIVISION 011 `E'INVIRO MENTAL HEALTH SER v "Ii ES
FIELD ACTIVITY REPORT
N n rE • Tel:
/ v acs 61-,A/,Am VALLey /'v
Street Town State Zip
PERSON IN CHARGE r natp.,
OR TNTF.RVTF.VJFn-. Name and Title l 6
TYPE OF FACILITY: ���j .P/J /�L-/� �1L gmu V�,
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FINDINGS:
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I acknowledge receipt of this report: SIGNATURE:
02/96 Title;_
Rev.
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DEC -0A -2007 11:54 PM P.02
i 3 Q(}. tastk 48 �c48 �sw"x53 20 "manhole
6p "ix60"vwx63 with 1 20" manhole lnveri 39" bo
�, 500- oa
750- loe 961x60 "wx51' with x-20" mantwla Invert 40h" fla=n
12 ' wih a 20" mnhole tuve 40x' ttom
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1RlLhelirnt 146"jic60"vvxS1 ' with ?r20" manhole Invert 40'x" ttdm
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.GALLON HEIGHT, HUGHT MANHOLE
CA LL014 LENGTH WIVM HEl W TO tNW TO OURET OtAMt's U PART
300 Sphere - S4" M& S1" " 44" 42!' 144, NWO 182
Y 500 101" :51'' 42" 3b" 39" 1 -20" NWOS 14
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750 9b" S2" 58" . slip 48" 1 -20" NW075 18
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t' 101" 52" 66" Sv, S611 1 -20" 00& 0006
1000
10 + 102" b0" 58" . S 0" 48" 2 -20" NW7 187
;c 1250" 11b° 55" 66" 57" 54" 2 -20" NW125 325
ip .1
_ x,1500* 143° 55" b6," 57" 54" 2 -20°' NW1 76
•part numbers shown for these tanks are for single compartment conflguratinns. Please cheek with Wancor for art
numbers and specific inkAraWn on two compartment con4`rguratlons. :;
DEC-03-2007 11:55 PM
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STAW24L 111MA11162410112
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MCORL
VVCMMNQ CAPACITY
Ua Galons /
TOTAL. MAMACMY
m us Gallmla / "ge
KMHT
LIENGTH
111111"HOLE
c"Slow1w
57 700
750 / 9"0
1007/3812
BV/ 1:295MM
192".1 1878Mm
lOr 1264IMM
w M
ST-iodo
1060/4012
1311 14M
51' / 129tlrrin
62"/ Worm"
137 / =78mm
24' I.D.
OT-1250
1250 4730
1404 / 5541
61- 1 120orm"
ar / 1575mm
1148- 1 3-r59mm
24"I.M
law soya
1768 / 6692
Bi- / 129&"M
Gr I 1576MM
17ri4496-0.
24, Ilk
1% IWL at_ • Aceoa M of &bo"
grade
Awd nmW be aseurod Sperber & INVIUmOP&Od accamm
a A L fr vahhm#Mr ir+./rOo JorrdlrMp
WAJVRA14MYFRALO PM*t&:h M4 vm m we the FRALO $MPT9GH' "Ok for a period of (ft yeah from ddto
of purchase against any manUbctUring (181111M, provicift the tank has been used end Installed In a000rderwo With
"W*dlohreft. written Instructions. FRALO ". at Its option, repair or ruplems. any tw* it deeffm to be do%*" snd
FRALOU oMWN*m under Vilm warranty ere "k&y Nmgod to the repair and/or replaawmmi of the deftcOw lamic FRALO
assumes no MWIty in cases of lmwmmr fneWhOlan or misuse. FRALO Is not mopwwftft tar any mouMM cmeApmt
11"d" or dmga& This wwranty,appil" only to the migbW Uw* Installallm.
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P61 12 ` Y_ J S
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL H H SE Z
— V 1
PROPOSAL FOR SEWAGE DISPOSAL TEM REPAIR O
YES Nd0/ Internal Use Oniv
❑ Repair Permit issued in last 5 years ❑ Not in Watershed O
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION - " /:J`I iv 41, (,0(,y f`�0.#+H TM # S-1 j 6 y 1'—'-1'7
OWNER'S NAME `-1 Pe fz T_ I cc % PHONE # '7i S 6 _8_1�y 1.
,,jj
MAILING ADDRESS y T N 19-!'` 4 V' A (-'L -j C) .S
APPLICANT .fib aJ14-P-0 b vii 1 c,,
Name & Relationship (i.e.. owner, tenant, contractor)
DATE ! 1 FACILITY TYPES PCHD COMPLAINT #
PROPOSED INSTALLER dWA-110 c�j,-J(4Fti'I PHONE#
ADDRESS . # S�i
PL
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 trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will. require submittal of proposal from licensed professional
engineer or registered architect.
I, as owner, or rep rted agent of owner agree to the conditions stated on this ft
SIGNATURE TITLE
i
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owners name
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers'.name and pVnumb 3. System repair to be perfordance with the
above proposal and cond
Pr posal A Proposal Denied
aL, I !ff
i spector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town 61); Pink (installer), Orange (Applicant)
PC -RP 99ML
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