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HomeMy WebLinkAbout2882DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.13 -1 -78 BOX 24 l.rum - q .; " .� . v�eTt YES SITE LOCATION OWNER'S NAME PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR T , -. - i Internal Use Only PERMIT # =w1 k e*r Permit Issued in last 5 years Ot 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 1 'Lae-Sue S !:� :) I ?r t �o t ~ ! - TyS E64 Q ct+rim PHONE # $91"f.5-q 30 -I't MAILING ADDRESS APPLICANT -0n Name & Relationship O.e., owner, tenant, contractor) DATE ,� /� i FACILITY TYPE PCHD COMPLAINTS PROPOSED INS LER °1�r q �,s ( (' /i-7" PHONE # f(K- f - 1 4 ©s 4 u= ADDRESS �Y ta.s`` i REGISTRATION /LICENSE # 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. f�ULA-(-e- 7'4-Kk WI tUCV 1000 6A L nrtc. p-EZ Z OIL- P L (*-S ; (C-A A,0 .1= I a L- nS' sI.L _ -TaA -� I his• aAr.c.i i--c V ,, c'°`ajc-Tome- I, as owner,agree to the conditions stated on this form SIGNATURE n. , sz- TITLE n DATE ? 2 d (Owner ,. _ V Il f, w erg, . -gu w X93 r is f SIGNATURE TITLE G DATE 4 ZI: (Installer) Prgggo eoDMM with the following conditions; 1. Procurement of any Town Permit, N applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplkxde 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 Departrnent. INTERNAL USE ONLY Proposal Approved is in comoliance with Proposal Denied ❑ Date COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 i P; PUTNIANI COUNTY DEPARTMENT OF HEALTH DI'VISION, OF ENNVIROINIMENITAI HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SE-WAGE TREATIN/lENINT SYSTEM Owner: ZdaA-114 i t Address: 1/7 al,-'S� �jl, 6z, 173 -2g Located at (street): 7M 4, Section: Block Lot Municipality: �6g6a? Watershed:. Date of Pre-soaking: z f SOIL PERCOLATION TEST DATA Witnessed by: - Date of Percolation Test:- Hole No. Run No. Time Start— Stop Elapse I Time I (min.) Depth to water from around ound surface (ini:hes.) St-, NV'ater le-vel drop inches Percolation Rate I min/inch i. 2 3 ! i i I I ! i 2 I 4 2_. 4 2 1 7-- jrnr:1 —Z, DESCRIPTION OF SOILS ENCOUNTER= 1-N TEST HOLES HOLE 9 HCL HOLE HOLE E as 4 4.5 ,v V 7.0' J.. 9.0, 10-01 Lidicate leve-1 at which zroundwailer, is encounter, - L-.idica'Lp- level at which mottl'lri.�:Isobser-v-,," A10A.11i, I_ diCate I.ev--1 to whIlch water leve, rises a:-,,--r being encountered Deep hole obser-y-ations made by: Date I /I t Z/z Des:La-:,. Profes�ional 'Narnc Address., j;Z-q-ature: A 'i td J ' yc�skt4 v;•J lie-1 l7Jdi ��O zfai r 1 w ll hI e ouL, col" _y. �v too, +o s s ` 's, R-1094; vi - ( /'-4 aff Ff02 y- �/ Ice 6 6 lcS 0-1/4/14r-5 7 o' MFR Ix THE kil 8 'A' r, ;FZC17 TR 41 VIN P4 now it 4v lea Z jqOS Z" 901w A06, SHA0,y LA :5 DUST VIEW pR ES 0 Kou LAKE C VIEW m -C Dh 1YOF WEST 8 too 08 4,1 A 7 0 7� 0 zw."'u FR Q LOW. ti bbld rj '"y O O 0 ti CD r11.3 L4 a ----- �.._...... 100 619 c nt-Ev ;- 3 37 AO 0 �l �jr y 07 .5" N-i-mAtff V,4L(,r—y IOC Li c, -f+- to y N rw 19 C, 60 rY v-,cv;- T t4