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HomeMy WebLinkAbout3075DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.63 -1 -3 BOX 25 0 IS I rm IN'S IN I SPIN 11 INS I INS ;dr, ;x -.1; 6 , IS NIN . .� r i f IS IS IS 03075 YES El SITE LOCATION OWNER'S NAME PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Use Only PERMIT # I L--r .. Repair Permit Issued in last 5 years W-"'Not in Watershed 1331e,- Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ Repair within 200 ft. of a watercourse or DEC-mapped wetland ❑ Joint Re'vle'w r .,5; e-, 'TOWN 1- iA ck TM # X 10 L' 1�� . PI-16NE V�— S -q MAILING ADDRESS K,1 j-) APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER "'i PHONE# -P ` ADDRESS Q lj, ,i JZ, i,%-, REGISTRATION /LICENSE # j l = J_ 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. . . . AA -- k) A -T Z 1> -i 5; ,-' \I? c, .=i 1, as ow ner,agree to, the conditions stated on this form SIGNATURE TITLE DATE (owner) the-seDtic..installer, agree to comply wit hAhe .conditions - of th D sEpiic system Lrepair SIGNATURE TITLE DATE (instiller)" jr 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 bed 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 nd 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 Propbsal tpprbVbd Proposal Deni ❑ All Inspector's Signature & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC-RP 99ML Rev. 2/07 r ,x�- 't.♦e: Y - y, ♦ E •' S t ttr1�J11 1 , . r_ _ a $,y r z5 +p 'a _ , , i s� 7. 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S 4.�. ir��� >�G [Y �. ^�7. `e_•.•a .T. .TrK "K r a - - n1.A>4C.vWbaa� 6V •Vr � 34 Columbus Ave Putnam Valley N.Y. 10579 914 - 760 6344 Joe Acqaviva Date 12/1/13 57 Shawanee R.D. License # 1137 Putnam Valley N.Y.. 10579 Septic repair A 1 15.6 S 1 20.0 C 2 28.0 D 2 25.0 ICA S\, a- Lj J v A Al. 0 9 � y .. I e� eo� r Putnam County Department of Health Division of Environmental Health Services 2 SETS Repair — Final Site Inspection Date: I Inspected b -- `. - Street.Locationr _ a �? _ t�° _. - =Owner: l . � -..a.: • :�;�•own: � v��'P�"r� ' � . - . - kepau'�ermit #. 1 S Installer: 1. 'Type of System: Conventional ❑ Alternate Comments: C- A e` 33® Qe-ckwser5 2. Se tic Tank Yes No -N /A Comments a. Septic tank size -1,000 ... 1,250 ... other ..... • Pre 2 -g e b. Septic tank installed level ....................... V c. 10' minimum from foundation .................. d. Distribution Box i. All outlets at same elevation (water tested) ... Q/ ii. Protected below frost ..... .. ....................... v iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box — properly set ........................... f. Trenches i. Systemcompletely opened for inspection ii. Length required jZffi- Length installed ^- ("(4, 0P A R 6 iii. Pie slope checked ... ............................... iv. Installed according to plan .......:............. V. 10 ft. from property line — 20 ft — foundations ... vi. Size of gravel 3/< -1 '/z " diameter clean ......... ii Depth of gravel in trench 12" minimum vii.- - - - - _ - -- _— -- - -- -- - - -- _ -- - viii. Ends capped .... ............................... g. Pumg or Dosed S stems 3. Sewa e System 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 ............................ Additional Comments: .idb vn y c RFSI Rev - 011312 t,4, TA PUTNAM COUNTY HEALTH DEPARTMENT ® , DIVISION OF ENVIRONMENTAL HEALTH SERVICES F I - PROPOSAL FO.R SEWAGE. TREATMENT SYSTEM REPAIR 10/ Internal Use Only PERMIT #C - R., 0 Imo' Repair Permit issued in last 5 years LNot 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 ��/ a�Gt l.✓ /I e TOWN P,�T'I'�a UG V TM #t1,2=43- —3 OWNER'S NAMETOe— v (/ ivq PH MAILING ADDRESS cS w`� APPLICANT ,,,L 0,,, / Name & Relationship (i.e., owner, tenant, contractor) DATE 1 3 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER M:_- C7Q- _Lt-�'Cr) � mil .�-Sr PHONE # `� xD ADDRESS CDGU in �-)J pui (k Ue REGISTRATION /LICENSE # t 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 r % I I I, as owner,agree to the conditions stated on this form / I - SIGNATURE TITLE U - P� DATE rC.. ?1 (owner) the seF,tlC iristaftr, agree •.o comply with tl�e c��nditi�_n of ti is-p,ermit for the SGatiC system -repair SIGNATURE TITLE Pokes '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 backfilyed until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pro sal o Pry�° osal e ❑ p P� � l`P +��� I �13 r I Inspector's Signature & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes fY No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 00 4Z e, CeA% 11 tAC, Vt%/M ProP®s�� a] A 'Var, A5 s A-11 WJ TLr - PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR SITE LOCATION OWNER'S NAME_ MAILING ADDRESS_ OFFICIAL USE ONLY �Q l l G •-0 I s• -" &V,y tick I w TM# (0a, (3 1­3 .cA _ K 05S i PHONE .6-,9-6 — 11 � 3 PERSON INTERVIEWED PCHD Complaint # ame & Relationship i.e., owner, tenant, etc. DATE W.-7-610 PROPOSED INSTALLER TYPE FACILITY Kf,.S A" (7 ¢A690-1 ` PHONE 42-6 r-a5"IS' ADDRESS a-q 6 0 Sc. w - j- , I — REGISTRATION# 3� e©T -25 Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. ' /-5 r1YCr'r'.d�6' aA, -c,, L(--f - n'J-�' "i�+ri.• _n+•,«n '._•.••.._•. �, TsJ'J�`2i�lj .�: .-perteu'tY n.rkn�'i.+,�' vv:�4. nf• -n - va . r'r N�_4, 'fNn Tn gip, n }nruiT -ni. y2. `n.•w.. -._ oA-nea b^'rvv .,7 -ae C-6- -w—s 3.....v.. v.a SIGNATURE - 'zt�� TITLE A C161' JV DATE Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title D E COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML - - - +.�� r.. _ ' ,i-:.. _ „u. ^c_ .•mre , aa�t w -P V � ,w. .ui�OY'�"�' .'......, c us . r , _ PUTNA�NI COUNTY DEPARTMENT OF HEALTH D£VISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM I Q(}caner:, C UlQ V l ✓�i Address: 15 � S �1w�I12G Lacated at (street), b 3 ( ) M Section. Block Lot Municipality: Watershed: SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: Date of Percolation Test: Hole No. Run No. Time Start — Sto p Elapse Time (min.) Depth to water from ground surface (inches.) Start - Stop water level drop is inches Percolation Rate min /inch 1 I 2 4 3 I . 2 3 4 S., 1 1 2 I 3 4 I . � I 4 l ' Notes: 1. Tests to be repeated at same depth until approximately equal percolation races are obtained at each percolation rest, hole. (i.e., < 1 min for 1=30 min/inch, < 2 min for 31 -60 min/ inch). All data to be submitted for review. 2. Depth measurements to be made from top of (tole. Farm DD-97,k ; of TEST PIT DATA , DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE #� HOLE # _ HOLE # HOLE # HOB # G. L. foci 2.0' ,Iq 2.5' L 0&fr 3.0' Ca �- 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 9.0' 10.0' Indicate level at which groundwater is encountered �t, ja��� c'a S6,01a, ese&S Indicate level at which mottling is observed �P Indicate level to which water level rises after being encountered Deep hole observations made by: l-- Date l ( Design Professional Name: Address: Signature: Design Professional = Seal