HomeMy WebLinkAbout2709DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
61. -2 -19
BOX 23
owl
la 6
Ni
f - r or
kP
02709
PUTNAM COUNTY HEALTH DEPARTMENT ^ , p 206 383a7�&
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
JeJ 13
_ PROPOSAL F.OR.SEWAGE TREATMENT. S_ YSTEM REPAIR
. ;. �:..� - . r -�r� : ��s.:,:^_.;�.rn --.. ... 7.e °. �..:.:: --. — . - er;. =�:- -. � o .. .- �•,�...r.�; r�`r:v ;_. ;�' -... • <:i�. .:�,.» ......t. �,.. -.tic �: +e ..:.. -. ... ....3 --::.. �� : R,.:'�: _ �.r �•.�.,v: -. m:.e.
YES NO Internal Use Only PERMIT # Y. V7 i- 1 3
❑ Repair Permit issued in last 5 years A Not in Watershed
❑ / 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
-a.4-
,q. a l�isi /aw,Qd; t?y,� TOW NP�w,,am (AA I!/ TM # lo
OWNER'S NAME .•1.,41 d �, ;r•+Fe p W e�; ter_ /��' -4c��f PHONE #�S/j .�–a�� d yf1,1
MAILING ADDRESS �7 G in raS fie fl o f../
APPLICANT CArt., auS
Name & Relationship (i.e., owner, tenant, contractor)
DATE a 1 3 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER ��.g,c. �uS Co'i CD. PHONE #
REGISTRATION /LICENSE # . / ///
/off
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. l f L
^,re 4 ..) Sc�ai i G LA *,.A1 � �S� gA I j> IO�S�1cC
I, as owner,agree to the conditions stated on this form
SIGNATURE 40e ;� � TITLE (2 �,- _ DATE
(owner) �-
::._i
the septic., installer, agree to comply with the conditions of,this:permi,ow the-septic-system repair. .
SIGNATURE TITLEef%,,,,._ DATE D/
(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 back�illed until authorization to do so has been obtained from the Department.
7 INTERNAL USE ONLY
Pr osa p v Pro sal need ❑
/ WIC c�ar� 10 13 ct 10 ( T
Inspe or's Signature 9f Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
Putnam County Department of Health
Division of Environmental Health Services
t (� SSTS Repair - Final Site Inspection
p
Date: f Inspected b AAf0L Installer: Cq (015 S CoAS�� �' ®♦
R?reet Locansn:..... ( -w �.?�► ol�ay _ nw�e - -
_.._
Town: Aft wg "Repair Permit #: -('71-13 ` TM # Ly2
J1. Type of System: Conventional O Alternate ❑ Comments:
2. Septic Tank
Yes
No
-N /A
C mments
a. Septic tank size -1,000 ... 1,250 ... other .....
gee%
✓
1&5 TLTL e k
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
rq,_ lXi3 �7 ota t'QA
d. Distribution Box
i. All outlets at same elevation (water tested) ...
L/
ii. Protected below frost .............................
L/
iii. Minimum 2 ft. Original soil between box &
trenches
�f
e. Junction Box - properly set ...........................
f. Trenches
i. System completely opened for inspection
ii. Length required Length installed
iii. Pipe slope checked ... ...............................
iv. Installed according to plan ....... :.............
v. 10 ft. from property line - 20 ft - foundations ...
Vi. Size of gravel % -1 '/1 " diameter clean .........
vii. Depth of gravel in trench 12" minimum._.... _......
viii. Ends ca ed .... ...............................
. Pump or Dosed Systems
3. Sewa e System Area
a. SSTS Area located as per approved 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