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03343
Sheet - of
PUTNAM COUNTY DEPARTMENT OF HEALTH
UTVYS!.ON OF .ENVIRONMENTAL HEATLIi �ERVTCES -
.D.q .— •. U° .: .,.. .,rues._ . .. q.y: •. •• •..p'• ...., ,. ,cJ.u..
FIELD ACTIVITY REPORT -
NAME' Tel:
Street Town Star Zip
PERSON IN CHARGE
Name and Title
TYPE OF FACILITY:
FINDINGS:
&',/2.
.1
Signature and Title
RFPnRT RFC.FTVFT) BY.'
I acknowledge receipt of this report: SIGNATURE;
02/96 Title:
Rev.
-'to 1i _ ._... _ ..._
d � f
.1
Signature and Title
RFPnRT RFC.FTVFT) BY.'
I acknowledge receipt of this report: SIGNATURE;
02/96 Title:
Rev.
TE S i r I I i i i A
DESCRIPTION OF SOILS ENlcbLWtTER_ED I-,N* TEST HOLES
HOLE = HOLE HOLE T HOLE
2.0'
2. 51'
3.5,
4
4. 5
7.0'
10.01
Ln6caze !e,/,-! at which groundl-vatier is encountered A142ALj
Indicate level at which mottling is obser�"ml_'.
Al
e!Al
1-ndici—e I.ev.* I to W111*c11 water [eve! rises e,-_ being e
encountered
Deer hole observations made bv:4, I Dar-a
2
Design Professional Name:
A. dd-r;-- s s:
I
YES NC
0 19
❑ 13
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
PUTNAM COUNTY HEALTH DEPARTMENT.
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use OnIX.�
Kapair Permit Issued In last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Re
Repair within 200 ft. of a watercourse or 0
PIA-675' TOWN
IC
PERMIM'114`110
LJ_,,Kot in Watershed
Z Delegated
❑ Joint Review
L (,,Z�TM #.:Z 3wf - 2- - 31
DATE FACILITYTYPE PCHD COMPLAINJA-,,-..
1*'7
ol+av 24T P
PROPOSED INSTALLER PHONE 1�5
11-ty ot I- ff i- r,, K V
ADDRESS REGISTRATION /LICENSE N
S_
Proposal (Include a separate sketch locating the house, property lines, ill adjacent wells within 200
foot of repair and the location of existing and proposed syrstern)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
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A-r-t- A4c 14. iw- o i 0fU 1`7 Z. - 4 4A*W0=*V*
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1, as owner,agree to the conditions stated on this form
/ yo ,- 3 F, 0 Wfe e_5 /n oae_ 7Z. ✓
9 "-,v e/, _e*? -s-tt& // a te, vt Ir / o -e 54 rum /,
SIGNATURE TITLE. o DATE Vt
......... .
iiii septic lin-itid d(,_ -d§rW io -0 dffip i y- with m FoIrtdidting-c ON I
(9voilylli, Ul at sy$W.
SIGNATURE TITLE DATE
nstall
Proposal acnroved with the AnI 09 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 duplWft showing:
a. Owners 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. Insialkwsname 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.
INTERNAL USE ONLY
Proposal Approved Proposal Denied
Co /2-
Inspectors Signature & Title D - B(pirationtate'
,Repair proposal is in compliance with applicable codes Yds NO ❑
COPIES: PCHD; Owner; Installer
PC-RP 99ML Rev. 2/07
MEMORY;TRANSAAI SS I ON REPORT
lik
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER : 932
DATE : JUN -27 10:38AM
TO . 85262595
DOCUMENT PAGES . 001
START TIME JUN -27 10:38AM
END TIME : JUN -2T 10:40AM
SENT PAGES : 001
STATUS : OK
FILE NUMBER 932 * ** SUCCESSFUL TX NOT ICE * **
,0 9l,L l f
PUTNAM COUNTY HEAL --rH DEPARTMENT lzt—
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
>P£30POSAa_ F Q SENlAQE IMW, 'rI1AEiNT Slim- 7EAII REPAIR
arttarr+ai Use Ora PB"mirr a 1 f
apex Parmh issue0 in test S years i1'QOL In Wat6r8hed
Q �Repalr within aoyera Censers. W. Mrarsds or Croton Falls ilea. {'+C� �411BgaterJ .
Q Re r - tnln Zoo ft- of a wale-:- u e or osc-m watlana Q Joint Revtaw
SITM l- OC^TION I e �Z ,. T-- ('�A�� TOWN �is-= "aL[+F- s�t�i✓l- c. C.. rTwq p - .-
OWNER'S NAME � � � fi le r u a- r'} C t cw '���_� PHONE aR#8S S�� 0� 1•f
MAILINC3ADOFMSS L_ca! ->o✓ T IPlirf P J
APPLI CANT
Name 8 Rolattonshlp p.o., owner, tenant. cmntrftctcW)
_ OIaTE FACILITY TYPE PCp•10 COf JS%
Jam] 0 ,,vr� -n�o H' � .�� <; a �' o�o-loNE n► s` - 2 � � �'
ACCFIESS _ J`'S -.✓.sa s� F� R t a�sz ` y =GC... ? -° .!r;�i WSJ id .Ic ". �- ``�
Proposal (Inciuda a :separate sltetcir W cateng the ttouaar property 1lntfts m011 adBeaara8 we01s twHthHt 200
feat of repair arad the location of existing and proposed ayatertt)
NOTE: The impartment may require submittal of proposed from licensed prafessional depending on the
nature and extent of the repair.
� /--+' z,.09— _
1, as owner,agrea to the condlilons stated on ttSis form
S113NATURE OATE T r
Q ®tnrnar9 �"
1, the septic instal r, agree to comply with tnaGconditfons of this permit 1+mr the septic system repair
S1C3NATURE /_�crl� -�/ TITL.E
(I..atalier) V4 1
�ronnsal etsrxovgd wrtf+ trsn folios>,r1no rbruiltlona:
1- tiro rerviont of afty TOwWS Permit. Ir appllCab1m-
2- 43LAertI'mmiora of as built Wapner aerapCta by V664194tIc sblWOWn lartgaaer +tAltrl: M 30 4aya CCIM a r001010. in ¢etrpiardtu nteaotrllTrg:
a- Outset's rummo. Sure Street Mmmo. Town and Tax Map rturnber
b. L.ocallon of Inseallad components tied to two fixed points
a. System daamiptlon (e.g.. 12SO gal. Concrete septic tank. etc.)
d. Installers• name and phorsa number
3. System repair to boo performed In accordance wtlh tno above proposal and condltiorm
4. The proposed SETS repair is considered a best fit design and Vvere to no gt8arerwbae to tlma dura*lan at which time
completed SOTS repair will lunation.
S. Np completed Work is to be bem-- illod until authorization to do so has been obtalnod from the Cepartm artt.
"Wre "AL uss qm"LX
Proposal Approved Proposal Oenlea L:3 " lo�s,s.QG l .cv0`s�'Or� is/r
Inspector's Signature a. Title t e ra on ate
Repair proposal IS In compflance wttn apgticable hides Yes Gr No O
COPIES: FICHE% Owner, installer
PC -FtP 99ML Ftay. 2/07
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