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BOX 25
02975
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02975
ICI 04(6' 1 OT 310
PUTNAM COUNTY HEALTH DEPARTMENT
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES t� --
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YES NO Internal Use Only PERMIT
❑ Repair Permit issued in last 5 years of in Watershed
❑ 1/ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
1:1 E Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION C4eoa4 Leo4o —f TOWN ? -Jf- t41+A- 'A4 ey TM #d a& t `]—oZ" LfA
OWNER'S NAME C —y S PHONE # 12-'s- 7 7 3 Y CPVS -)
MAILING ADDRESS A24 gfpM L"6•Ef {qtr r%I, UA �- , -IVi (Q�Ildtr
APPLICANT •61044Lp
Name & Relationship (i.e., owner, tenant, ntra joLL
DATE t Lt FACILITY TYPES PCHD COMPLAINT #
PROPOSED INSTALLER +.0 OCA46jewi OZ94054f,, 4/rr 40p PHONE # 3S-
y�
ADDRESS �'r-e l9e�iJ,� L��y_ (�( _ I'"71�_ REGISTRATION /LICENSE # /d V
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.
+- ! in. /1'.t �`.C�'T�l E/ aQ- TT.GL- c`l4••Eh
I, as owner,agre to the conditions stated on this form
SIGNATUR / TITLE ;ryy;p DATE
_._ (owner). _
inv' "aisNii� illSia ai; ia:3i6e tv C,ur7ipi'q wi ih IhG con uuiui.a vi t.n 17a iiii it'll vi uro a�N►i�. Sj%ytv�i� ivpaif
SIGNATUR TITLE&r -�' DATE I'f 13
(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$h6d until authorization to do so has been obtained from the Department.
Ins6ector's Siaft ure & Title
is in
INTERNAL USE ONLY
Pr gosal Denied
with aoDlicable codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
li 1�
Date
Yes
&tl III I �
Expiration Date
No ❑
Rev. 2/07
PA
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PUTINAIN C® . NI TY DEPARTMENT OF HEALTH
REVISION OF ENVIRONMENTAL DENTAL ALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE - TREATMENT SYSTEM
Owner:.
[,acated at (streiett):
j%4 unicipality:
D a to of Pre -soa kiatg:
Address: � I Cel % L.0 I P1
17 2 -
TM 4 Section: Block Lot
Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by: _
Date of Percolation Test:
Role �o.
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
Z
�
k3
. _.__:._,....:...._
w.
I
2
3
4
I
�
2
3
i
4.
1
�
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., < l min for 1-34 thin/ inch, < ? min for 31-60 min inch).
All data to be submitted for review.
3. Depth measurements to be made from [op of hole.
Form DD -9i,p�
Putnam County Department of Health
Division of Environmental. Health Services
SSTS Repair — Final Site Inspection
Date: t 1
_ k? � � Inspected by: f (/�Q L __, Installer: � {_met' I _
^K. .�.._ �_ .�":..>.. ..[.c+,•.,�.._ . .. ... .. � i1 J -o . ....
Town: N Repair Permit :a3 $ 3 TM # �; 7
1. Type of System: Conventional ❑ Alternate 5tommen ts: 330 ke—cTorg ei�. X '33
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) ...
ii. Protected below frost ..............................
/
J
iii. Minimum 2 ft. Original soil between box &
trenches
e, Junction Box — properly set ................. . .........
f. Trenches
i. System completel4 2pened for inspection
ii. Length required Length installed
iii. Pie slope checked ... ...............................
le,
iv. Installed according to plan .......:.............
v. 10 ft. from property line — 20 ft — foundations ...
✓
vi. Size of gravel 1/4 - 1 '/z " diameter clean .........
viii. Ends capped .... ...............................
✓
g. 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
f Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
S - ", Avrr �s
01/�4 Iot� C-�� � -
7 �2.F'SI Rev 011312