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Home My WebLink About2720DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 61.-2-36 BOX 23 kr , 1 , . i L E •, , 02720 PUTNAM COUNTY HEALTH DEPARTMENT I DIVISION OF ENVIRONMENTAL HEALTH SERVICES I ,. _ .......... _ .... - ..._..._ _ .....� _ — - R — y��a T_ �._ t tip+ '�v : X11 "S �a�/�►�ii.r�.'TiL aflil`NT SY- S-i' r Internal Use Only PERMIT # U L� Repair Permit issued in last 5 years IV' 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 OWNER'S NA MAILING ADC APPLICANT TM# W -2 ---7,L. 1 DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER �yti�� ,,�,��,:j��a PHONE # ADDRESS ';5 r , REGISTRATION /LICENSE # 10 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. j 1 i Zr2 �.L r 0—�'ri z 4 n-J ' iA ":-1_el ILCI- ht�'1' iJf`1 iCi� I, as owner,agree to the conditions stated on this form SIGNATURE ITLE CLOsiyl DATE - 1" the septic sgre� to cornpiy an tri -- conditons -of this-permit °rcrthe septic system repair' n. SIGNATURE TITLE , ` 'DATE (Installer) Proposal approved with the with the foll��nd�ons: 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 w completed SSTS repair will function. 5. No completed work is to be backfijl ed until authorization to do so has been obtained from the Department. 7 INTERNAL USE ONLY Pro sal prov Proposal Denied ❑ Inspector's Signatuille &Title l u N %c Date Expiration Date Repair proposal is in compliance with applicable codes Yes fl/ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 tali ()S &r Ii" Homeowner: Michael and Shahla Jannetta 226 Canopus Hollow Road Putnam Valley, NY 10579 -1404 Town of Putnam Valley Tax Map: 61 -2 -36 Installer: Phil! i ��1r11� {,rsp (t franca ail f 1�� Precision Excavating Inc. 3 Rochambeau Road Garrison, NY 10524 (845) 736 -0571 Description of Repair to System: Installation of 150' of Fields with 1112 Washed Stone Installation Complete: 10 -10-12 Scale: 1" to 20' Legend: A -1 =35.5' B =1 =12' A -2 =26' B -2 =26' A -3 =22' B -3 =31.5' A -4 =19.5' B -4 =38' Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site Inspection Date: l G C t1- ) II Inspected by: L__ Installer: Pf�c �` S tv /� Streeti.ocatign 2 �_.__.n.dn�„1 �i16L16a Qp? Owner: wft a _ s 1 own:' stL�n4M �%a. kW . -� - . - }Zepair 1'eriiiif #: ' ' I(- LI'g`r�' T I'M # . b I , /. .� _ .. A. = 1. Type of System: Conventional Alternate D Comments: 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) ... f ii. Protected below frost . . . . ......................... l/ 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 Length installed __L5 5 V ,/ W. Pipe slope checked ... ............................... iv. Installed according to plan ..................... v. 10 ft. from property line — 20 ft — foundations ... vi. Size of gravel 1/4 - 1 %z " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... viii. Ends ca ed .... .......................:....... g. Pump or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per a roved laps 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 ......... f 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 . .v .... ..�. .. .. n. ... ... > _r .�r..� 1. L.. !nw •r ..w c .a ....ia. ♦ • • r .w ... a,. -. .. ... . *.s .• a rv:i_....M. •6' aN Orrn .or + e > -.-. � n+.i � ., + �I Homeowner. Michael and Shahla Jannetta 226 Canopus Hollow Road Putnam Valley, NY 10579 -1404 Town of Putnam Valley Tax Map: 61 -2 -36 Installer: Philip Leonforte (License #1022) Precision Excavating Inc. 3 Rochambeau Road Garrison, NY 10524 (845) 736-0571 Description of Repair to System: Installation of 150' of Fields with 11/2' Washed Stone t 1%0 a-w (( 0 _0 •4� Qf Hcu� C', --Homeowner: _ Michael and Shahla Jannetta 226 Canopus Hollow Road Putnam Valley, NY 10579 -1404 Town of Putnam Valley Tax Map: 61 -2 -36 Installer: Philip Leonforte (License #1022) Precision Excavating Inc. 3 Rochambeau Road Garrison, NY 10524 (845) 736-0571 Description of Repair to System: Installation of 150' of Fields with 11/2" Washed Stone V1 %C1 a -Ul 'A <:,il�, I i s Public Kealth Director DEPART OF HEALTH 1 Geneva Road - ' ,Brewster, New York 10509 Associate Public Health Director Director of Patient Servieas ATTENTION: (3 JOSEPH PARAVATI a GENE REED All information below must be fft completed prior to any scheduling. DATE: 10 --1 — t ENGINEER OR FIRM: �i�n : g: c,r, c n p.� r r, a PHONE #: ?MS-:J1 %-OG -T1 REASON: DEEPS: )( - PERCS: o PUMP TEST: a ROAD /STREET: TOWN: TAX MAP#: SUBDIVISION: LOT #: OWNER: YES NO � r V.:....... Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs. PropWso SM within 500 feet of a rpervoir. res i oi_t -44 or: coatrvi' Proposed SETS within 200 feet of a watercourse or a DEC wetland. Proposed SSTS design flow greater than 1000 gallous/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. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered Yg to any of the questions, NYCDEP most witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professional and NYCDEP. 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- TM: COINR�PfS: (FIELDTEST) TEST PIT DATA � DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES Indicate level at which groundwater is encountered S (510W CK? / s eTg��) Indicate level at which mottling is observed Indicate level to which water level rises after being encountered O Deep hole observations made by: Date j® 4'Z Design Professional Name: Address: S i Quature: Design Professional = Seal