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HomeMy WebLinkAbout2635DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -27 BOX 22 I" Iwo IN I Is 0 j.1 NJ ., I6 f �.Vp % - . r '� - �I, . , 02635 ' - •. � f',t;'�a' fi Vii'?. S � -3..,. �d� 3 t� PUTNAM' COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL , ... SEWAGE DISPOSAL .. .. -- -- - .._...., -..:- ._d .. - . _ `� � �� •. .. SITE LOCATION OWNER'S NAME /Z MAILING ADDRESS OFFICIAL USE ONLY 1-e elLI 1011141114i41ITM# = - PHONE ` - - / - 1 e`!w 1&_,9 PERSON INTERVIEWED�rGG��/_�p��ti� -� PCHD Complaint # ame W Relationship (i.e., owner, tenant, etc.) DATE _ /�'!_ TYPE FACILITY d� S PROPOSED INSTALLER,�/Z',,z,_) �!KJCA .1c•` C PHONE 2,2_7 V,SU ADDRESS G%� , �%a%Jt°W�' LC REGISTRATION# , J 72- Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may rewire submittal of proposal from licensed professional engineer or registered architect. ,UGL.ifl/P'v -yo"-a4 - .0L ­r / Pmt_ -•G .00004r S :0- » I; as-owner, or reported agent of orvn r gree to the conditions slated o this foim. SIGNATUR w TITLE '� ��d4- DATE — j'y 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. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. -1 * Proposal approved ,ector's Signature & Title D TE is White (PCID); Yellow (Town BI); Pink (applicant) 19ML PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES!��_'` PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES N Internal Use Only PERMIT ❑ / Repair Permit issued in last 5 years Not in Watershed ❑ C7 Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ Repair within 200 ft. of awtt watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION '//� q%4kf A/& TOWN TM # 152, —'3 — ,2 7 OWNER'S NAME- "f � y(>&5. � _ ` (/-PHONE # 9/7-1'2_3 - 9Ba2f MAILING ADDRESS 7 APPLICANT cl� Name & i. DATE PROPOSED INSTALLER _t ADDRESS hip((14., owner, tenant, contractor) FACILITY TYPE J201V 6V PCHD COMPLAINT # ,-Z/ //x PHONE # iS -A5' REGISTRATION /LICENSE # 097 Pro sal nclude a 4k� A R � (I rate 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 I, as owner,agree to the 7 n stated o his form T ITLE SI NAT R y l �1� SATE (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE ZIA kt TITLE DATE 1W I/ (Installer) ProR=I MRS BM 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 bed 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 functio '. 5. No completed work is to be bac led until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pro sa proved ® P Wop o I Denied ❑ , Inspector's Signature & litle Date / Expiration Date Repair proposal is in compliance with piicable codes Yes ❑/ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 7� ezham i wal /Co C� 51q / // T C El F191H A. 2Y 17' 22' 27' -6' 51 5l 51 62 T hki ll �0 ilo0 Opoer. M7 H YU M A-E q6,hw),w, cqnlke 10573 J4 50 -3 -a7 Nell T 50-- 745 �'�C /P flyl 2 I sc� pq T04 U14 it . r Owvyer.- TE HYUP(, ARAS- 9U&v,w cb,-Ae, py IGO 14? To a r Nell Fo--T-� ql,7 — q,23 qO15 I .x %45 iy Ix- L E 000' ljop 4vt X C/pD, a Y- PtiTNAM COUNTY DEPARTMENT OF HEAL'T'H DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREAT)N[ENT SYSTEM Owner- Address: -7T -5 Located at (street): TM:* Section: -5? Slock Lat Municipality: l�4M VY Watershed: SOIL PERCOLATION TEST DAT:k Witnessed by: A L Date of Pre - soaking: �(3 (i Date of Percolation Test: a 1'.t ll Hole No. Run No. Time Start — Stop Elapse Time (min,) Depth to. water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min. /inch 102 - ( 0 2 ��P 2� �, 2 `�- log 3 1 oc�. ,1 c & 2 3 f 4 t 5 i i�j2 - os 26 2t- 2-1 o f 2 3D 1- 4 - 26 z T)2 �- 3 31-12"3 ho 2 -26 /Z I '1 Yy 1� 4 5 2 3 4 3 k ` 2 3 4 5 ' Notes Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < i min for 1-30 min/inch, < 2 min for 3 1-60 min /inch). All data to be submitted for review. Depth measurements to be made from top of hole. Form DD-97. ae 1 )('- TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES 1 DEPTH HOLE # r HOLE # HOLE # HOLE # HOLE # G. L. 0.5' 2.0' �r�+�►r� 2.5'` 3.0' 3.5' 4.0' 4.5' Lt 11� 5.0' 5.5' 6.0' n 6.5' 7.0' 7.5' 8.5' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered I-U'� (s )A/ d�os Va Indicate level at which mottling is observed �� M �1 ©OS(f vPb Indicate level to which water level rises after being encountered Deep hole observations made by: Mi- Date � Design Professional Name: Address: Signature: Design Professional = Seal Sheet of l PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT NAI�,fF • �J 1� 1 ��L � Tel: Ny Street Town State Zip PERSON IN CHARGE A0� LG1�SJ� &5Av0j1DN I Na e d Title TYPE OF FACCMITY : r INS CTQR TF.T : Signature and -Title TT- V FXMT TrnTT<TCT% nV• I ackowledge receipt of this report: SIGNATURE; Title..