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Home My WebLink About3110DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.72 -1 -27 BOX 25 I Ir! I I I I I L r$ P � 1 Is .r I 11 IL 4' 1 "1 L ■1 1 r 1 :�16TH11 I, T YES tea, / hJ' SITE LOCATION PUTNAM COUNTY HEALTH DEPARTMENT DIVISION'ZOF.ENVIRONMENTAL HEALTH. SERVICES PROPOSAL =YFOR' SEWAGE TREATMENT SYSTEM REPAIR NO ;} Internal Use Only PER # ., Repair Permit issued, in last 5 years Not in Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ - Delegated ❑ Repair within Zoo ft. of a watercourse or DEC - mapped wetland ❑ .. Joint Review TOWN U ,, TM # g2,7.2 - / °Z% OWNER'S NAME 'C-L.VIrk, ked-C., PHONE #an 2,112-Z MAILING ADDRESS _!571Rofc /IZS Zgg!%n t APPLICANT Name & Relationship Q.e., owner, C DATE /if�9�c�, l �j ,Zp')Z- FACILITY TYPE S� PCHD COMPLAINT PROPOSED INSTALLER �R%lUGt-�'C. , �� PHONE # C� �S-(( Z,7--t7UZP ADDRESS 22 nfauP_Vs il✓ - tee✓ ►� ,(„z REGISTRATION /LICEN_$E. _ /0/ ? 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. ST o LL /T« s "/y TTY•^ r; : °�i /iii �,yr� I, as owner,agree to the conditions 7dg;form SIGNATURE w TITLE x.,e y DATE �- (owner) I,.!l e_seftic'insta!ler, an-ree to comply with the conditions of this permit fc/ the Jaeimis s;Vs!em rep - -;r SIGNATUR TITLE _'.eLJ ._.r . _DATE 3 - 1t1-T ZG/ I- (installer) Proposal approved with the folio ing 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 backfil until authorization to do so has been obtained from the Department. / INTERNAL USE ONLY Pro posall Approv Proposal Denied ❑ Inspector's Signature & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes ff / No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 S. ut Jv.. Q a S 2 *46W Eke.,, ®c� 6017 Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site Inspection 11 Date: 3 �� 2 Inspected by: , L Installer: A rroW �x fa ✓aTi tt Street Locate n: y-2'1 O�twJw.s 1.a�(e Qd Owner: Re Town: p�naM 1/aj�Gl_ - Repair Permit #: G 1. Type of System: Conventional ternate Comments: L,1 c R 330 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 .................. G d. Distribution Box o�Q, 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. System completely opened for inspection ii. Length required Length installed _L&!_ &! -iii. Pipe slope checked ... ............................... iv. Installed according to plan ..................... v. 10 ft. from property line — 20 ft — foundations ... vi. Size of gravel 1/4 - 1 %z " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... - ... �< - r.., •,iia. Ends ca�sd` -.r. _.. _ -- <.. .... . _ . - - J ... _ � - -- �:- _.. ._.._....�...__ " . Pumpor Dosed Systems 3. Sewage 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: 1 /k �( A e q - �tA& p �h4 4 It SOW RCV(APQAeb gxP111 .rn� S5 f5 -'r t a ,,Ve.W � a � 6we�� OWW- wt,S vnWe- o �o so 1AL to ��,.:, ^C ;j cos +• RFS Rev - 011312 . �eall�• Qe a�'on��- A T15)Ak1 - eco fthA t+L-4 OWA(er` A %rej ra�� t��er% (�1/a r away HM COvLrr b CODA c oj�, lw\,A �t +e P i ', faIi"`re. N� u/J M i ��si�titr �a1so i�LCOd�nMe **�� w 4,, 1 ! kk al8o vT h.l'-c-�r P P . . PUTNINANI COLNITY DEPARTTYMNT OF HEALTH DMSION OF ENINVIRONNMEINTAL HEALTH SERVICES DESIGN DATA SHEr-ET -' STUBSURf ACE SEWAGE TREAT�IENIT S YSTEM Owner: Address: Lk Rdl Located at (street): TTY1 ""' Section: r Bloc, Lot lyfurlicipality: '04A IIZ Watershed: - SOIL PERCOLATION TEST DATA Witnessed by: Alk Date'of Pre-soaking. Date of Percolation Test:- 9 Mr Hole No. Run No Time Start - Stop J Elapse T . ime (min.) Depth to water f- mm round d surface Start - Stop Water level drop in inches Percolation Rate min/inch -b 2 .3 .4 2 2 3 4 .3 4 Notes: I T-f7r rn -'iP nnnpnr�•i -,ir rienrh iinril t .DES ESCPJPTIOiN OF SOiL6 0, H 0 L E Hot--- HOLE EP T rl 1.01 2.0' 2.:" 3.0' ko A 3. 5' ZO (-,Iocw 5.01 rid ALA l� '0000� TO' 1'.5! 8 -0' hidicat,e leve! at which zioundwaier is encountered �S� �1ole '�lu�� -t�b�^ �t"A�� S�'I�'t � Indicate [ev-.1 at which n-mottling is obse—i sec! 4 Indicate diicai-! Level to w�mclri water level uses afLer being encountered Deem hole observations, made bv: MpL Dale 3114/ 1 -L Design Professional Mane: Ad-dre S S: Si cnat-ure : HEALTH D- DIVISION OF ENVIRONMENTAL HEALTH SERVICES THIS IS NOT A REPAIR PERMIT PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All information below must be fullv completed prior to any scheduling SITE LOCATION RV 'TOWN TM # OWNER'S NAME PHONE# MAILING ADDRESS 5 Q 6 PROPOSED CONTRACTOR/INSTALLER PHONE# ADDRESS REGISTRATION /LICENSE # Re 6n for exoloration: Gfailure to surface 4 back-up in house . ❑ find limits of system for repair ❑ other (explain below) A � Signature & Title FOR COUNTY USE ONLY tAr- Appointment Date: —Time: TT Ictt� kly: excel: septic Date r i • c?v ..4rLi �� = •','.,"-'AYR T.IV PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONTMENTAL EM4,LTH S]ERVXCES REQUEST FOR FIELD TESnNG All information must bed completed prior to any scheduling. Date:— -13 - ,Z Enginleer or Firth: �- t c �.c Phone #: M - Z` Person to Cootactr= wt ❑ New Cognstruction �ZRepair Program ❑ Addition Program ' Treason: 1� Deeps ❑ Peres ❑ Pump Vest Road /Street: Towns: Subdivision: Tax Map #: L i Lot #: Owner: RVInl P► 4 ❑ ]Project not within NYC Watershed It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. 1f you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professions and NYCDEP. If a. project has been determined to be Delegated based on the above response and then subsequent information indicates IWCDlEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNT TY USE $yj1_Y DATE: 5t l `f I TIME: COMMENTS: Req.for field testAly 4/16/2009 NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL, TES' L G YES NO ❑ Proposed SETS within the drainage basin of West Branch, Croton balls, or Boyds Corner reservoirs. ❑ R Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ RP Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ K Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ F Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. 1f you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professions and NYCDEP. If a. project has been determined to be Delegated based on the above response and then subsequent information indicates IWCDlEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNT TY USE $yj1_Y DATE: 5t l `f I TIME: COMMENTS: Req.for field testAly 4/16/2009 e ' w..0 n s osc&u twi R w . Q Mo - ---�----��---'-�--�'-^-'+--^---=~-^--------- �-----~' 'r------� '- ^-'�-----�'�----------- ' '