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02813
PUTNAM COUNTY HEALTH DEPARTMENT ► r LJ ✓
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ✓
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
...v.. , ~YES ~ „NO/ _ - Internal Use Only PERMIT #/2 - <D q -
❑ 0
11 o
SITE LOCATION
OWNER'S NAME
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
within 200 ft. of a watercourse or
MAILING ADDRESS V X& 0 SG
APPLICANT
TOWN
J'(^
wetland
V ot in Water
elegated
❑ Joint Review
TM# 6X, - Z - 1SC
NE # K4%S 3 1 b O QVS
Name & Relationship (i.e., owner, tenant contractor)
DATE % FACILITY TYPE PCHD COMPLAINT #
PROPOSED INS ALLER LQGL lj �& PHONE #
ADDRESS 3 4 t arQL 6V Gtr 4 ��JC4 WREGISTRATION /LICENSE #ZQ X3Z/'', %
—7077 t7
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 ext nt o�tpe re/pairg
wriv,o ~0,1t f—(,Q4 f7GS w`dy -l„ S " k/ S 0 ,�- I ✓ yr l �
J
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE ®i�'rte2 DATE
(owner)
I, the sep c ins Iler, a e comply with the conditions of this permit for the septic system repair e
SIGNATURE ` ir�� TITLE P''4� DATE /
(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 backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
Ael /' - 6 t-
/
Inspector's Signature & Title Da e Expi ation Date
Repair proposal is in compliance with applicable codes Yes I / No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
1�1\%l
Sheet Of_L
PUTNAM COUNTY DEPARTMENT OF HEALTH
IT., vn?. iAoM.s.-h.1,4.L
.r.�. -..+.
FIELD ACTIVITY REPORT
AnT)RF�4s 7J4
Street Town State Zip
PERSON IN CHARGE
'Name and Title
TYPE OF FACILITY:
FINDINGS:
Signature and Title
REPORT RFC EWF:U_BV:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title
Rev.
W
A d `3
sk,Lv -c tae/
7�� s
Signature and Title
REPORT RFC EWF:U_BV:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title
Rev.
. ._ tt- `i..�'� `w. .CT'.4.+av T.r ur• �.....a -c:,M - .. .. u..e >- r.: �...e+- w....r.".
�i''N`A►1%i COUNTY DEPART�L��,;jJf ^M:('NT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMIENT SYSTEM
Owner: GLUem Address: `1X 6 05c,-,<vc,ta- La ce
el 19,
Located at (street): TM At Section: _ Block — Lot
Municipality: h�u-iMQWL yadlese Watershed: A�IcA -avw
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre - soaking: Date of Percolation Test:
Hole No.
Run No.
Time
Start —
Stop
Elapse
Time
(min.)
Depth to .
water from
Found
surface
(inches)
Start - Stop
Water '
level drop
in inches
Percolation
Rate
min/inch
1
Z
3
4
w_
1
2
3
4
1
2
3
4
5-
I
2
3
4
Notes:
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < t min for 1-30 min/inch, < 2 min for 31 -60 miniin6).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97, aq i of .,
TEST PIT DATA
DESCRIPTION OF SOILS lENCQtNTERED IN TEST HOLES
;I-10�`# •. •, .. - Hol
G.L. _
0.5'
1.0'
1.5' 5 to
2.0'
2.5'
3.0' lqd,
3.5'
4.0'
4.5' tv44,tr Lv
5.5'
6.0' .
7.0'
7.5'
8.0'
8.5'
9.0'
Indicate level at which groundwater is encountered lf, a
Indicate level at which mottling is observed _ 42& z :�ae Ao 4/?k 1Coax -l",
Indicate level to which water level rises after being encountered -X, T2;
Deep hole observations made by: IZczo( Date
Design Professional Name:
Address:
Signature:
Design Professional = Seal
10001
06/11/2013 09:58 FAX
AI
r' I
PUTNAM COUNTY HEALTH DEPARTMENT
Di IISI.ON OF ENVIRONMENTAL HEALTH SERVICES
�HIS IS NOT A REPAIR PERMIT
I
All InformaticH v below must be fUlly compMed prior to any schedutfng
-//, L6 - 4 VW,
SITE LOCATION ��O Q. C }41444- TOWN �I iv�� TM # tea-• Z :. `�y
OWNER'S NAME ri' UU aver PHONE # r y(� Lcnily
MAILING ADORI S ,.
PROPOSED CON rRA CTOI INSTALLER Lto nq uq PHONE #
ADORES$ ZPJ 4 REGISTFiATION /LICENSE # , 03714' (DY . .
aaArL i
sc 1or*:
i) re tp,surf tin a CJ b ck -up In house K find limits of sys m for repair ❑ other (explain bokhv).
i�nl K f I f,� 6 n.,�rtA �1 � 2�__ L) n�.t
Date:
kly.makseptic
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Putnam County Department of Health
Division of Environmental Health Services
SSTS Repair - Final Site Inspection
Date: 61n2l _ Inspected.by: Ca, Zec Installer: / oca %6U", ):�X us s &'.
Street Location: X2_9 O id a . L /C. Owner: Y-
1' Repa:' ?crmit-n :
1. Type of System: Conventional O Alternate O Comments:
2. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size 1,000... 1,250 ... other .....
15-00 &P—lel
� ledP t �c1C
b. Septic tank installed level ......................
c. 10' minimum from'foundation ..................
/
d. Distribution Box
i. All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
iii. Minimum 2 ft. Original soil between box &
trenches
e. Junction Box - property set .......:...................
E Trenches
i. Systeiricompletely opened for inspection
ii. Length required Length installed
iii. Pie slope checked ..................................
iv. Installed according to plan .....................
ew- Aeookf
v. 10 ft. from property line - 20 ft - foundations ...
X -aws c k
vi. Size of gravel % - 1 %z " diameter clean .........
vii. Depth of gravel in trench 12" minimum .........
_ .. _..._ .._..._ ._ viii.
-
. 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
E Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
RFSI Rev - 011312
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