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03073
QV ® a D
PUTNAM COUNTY HEALTH DEPARTMENT 6 ;
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ?.
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
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YES NO /� Internal Use Only PERMIT #
❑ Repair Permit issued in last 5 years 2elegated
ot in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
i VOW12A4& h Pd TOWN P,)ldom V41fiA9 TM #
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/..if e4,L PHONE # �`! S� % 24 � tj
Name & Relationship (i.e., owner,
DATE /0/31/13 FACILITY TYPE `— �- Fmj PCHD COMPLAINT #
PROPOSED INSTALLER 406,44 �"�`1 (9/0M4 PHONE # N ��1 �3S✓
ADDRESS 3 r.1&t I'd REGISTRATION /LICENSE # /® )i3
16s�7
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.
I, as owner gree to :the conditions stated on this form
SIGNATURE TITLE� DATE (31
(owner)
- I,:the septic ' taller, agree to comply with e conditions of this permit for the septic system repair
SIGNATURE_ _• TITLE .. 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.
Proposal Approved
Signature & Title
is in compliance with
INTERNAL USE ONLY
Proposal Denied
cable codes
Date
Yes
Vof
Date
I/ No D
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
(d*
C4)
PUTNAM COUNTY
NOV 0 6 2013
DEPARTMENT OF HEALTH
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Putnam County Department of Health
Division of Environmental Health Services
SSTS Repair — Final Site Inspection
Date: / /r/ �/�3 Inspected by: iZt��,{� Installer: 4cee / 4� vy
S�ceetiocation: °s'" ;7VtasriUiti 'p2; - l�ir6ilc ^r: `!ti \LrSci...✓l0.°GY
Town: 'rvJnc .r, ✓,;k Repair Permit #: R- Z / l 3 TM # 6 .L, ;.6 —
1. Type of System: Conventional 0 Alternate 0 Comments:
2. Septic Tank
Yes
' No
N/A
Comments
a. Septic tank size ' 1,000 1,250 ... other .....
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b. Septic tank installe 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 — properly set ...........................
f. Trenches
i. Systenitompletely opened for inspection
ii. Length required Length installed
Skerri-- cave, 4- lava 1z-,.k
iii. Pie slope checked ... ...............................
iv. Installed according to plan .....................
V.. 10 ft. from property line — 20 ft — foundations ...
vi. Size of gravel % - 1 '/2 " diameter clean .........
,.
vii. Moth of gravel in trench 12" m1n1M. UM
viii. Ends capped ... . ...... .........................
g. Pump or Dosed Systems
3. Sewa e S stem 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 ............................
'� y
Additional Comments:
RFSI Rev - 011312
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