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74. -1 -5B 19
BOX 28
03505
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~ PUTNAM COUNTY HEALTH DEPARTMENT
.DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_..PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR,
Internal Use Only PERMIT #
13 Repair Permit issued in last 5 years ❑ Not in Watershed
[J Repair within Boyd's Corners, W. Branch or Croton Falls Res. ❑ Delegated
[] Repairrww`ithiin�200 tt. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION �{Z tr�e. Q�� TOWN ;; V&Jlf TM #_-
OWNER'S NAME Aai Q S ` PHONE�j
MAILING ADDRESS y Z � �.c "1�-1� .i rc�.v► �1`v.`� C �jQnec �C )
APPLICANT
0
Name & Relationship (i.e., owner,
DATE F� �� p� FACILITY TYPE PCHD COMPLAINT # !Uu
PROPOSED INSTALLER �}r�j�LU.� �� t PHONE #''�
ADDRESS I`c1. RQ-lk �cT Gk�n :c�,�ic�- �l l . REGISTRATION /LICENSE #
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,agree to the conditions stated on this form �j
SIGNATU r TITLE � A-T DATE -0, 0 O
(owner)
"1, tfibLseoi;.irrt-ailhr, a roe to comply with the condition -s.of th&permit for the.septic.system repair... • , ,
SIGNATORE c ----� TITLE 0Lw- -, - DATE tt
(installer)
Proposal approve • the followino 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 Tar, 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.
INTERNAL USE ONLY
Proposal Approved
ctor's Sig
proposal is ,In compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Proposal Denied ❑
Date
es Yes ❑
Expiration Date
No ❑
Rev. 2/07
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SGT -15 -8001 03:4TPM FROWINVIR011NENT4L HEALTH 845ZTSTAZI
SHERLiT•A AMLER, MD. MS, F'AAP
CGrrr+rr +ssioner of HaolrH
°•LORETTA MOLINARI, RN, MSN �
�. ;7 ; .7. ., .: . _. •- .
DEPARTMENT OF HEALTH
I Geneva Road, Stowster. New York 10309
M011ST FOR FIELD TESTING
All information below must lie fully completed prior to any scheduling.
1-614 P 002/302 F -38:
RUBERT I BOND1
Coun/u accuri►e
ROBE RT.MURRIS...PE.
• = n:citor �gj!'FmifrnR+nerirril• Xeair•h ` ° "'
DATE b 1(2 6
ENGINEER OR FIRIYI':� PHONE 4:�4 29 0e�2-y
PERSON TO CONTACT:.- .�v_Ov_��f�
NEW CONSTRUCTION Imo,•, PAIR PROGRAM Q ADDITION PROGRAM
I2Er#SO'4: :UF ;F: FRCS: El PUMP TEST: ED ROAWSTREET: ' AtA, V'V.
TOWN., �a TAX ..MAP
SUBDIVISIOI`T:�..._.�...- LOT
l rVC, +l2&P CRITERIA FOR JOIN'r. RE'VI)xW, TjLWIT14)I U1NG OF' SOIL 'TV-STING
�n
YES NO.
Proposed SSTS within the drainage basin of West Branch or Boyds C?ornsr &
Croton Falls Reservoirs.
0 Proposed SSTS .within 500 feet of a reservoir, reservoir stem or control lake.
G C' Proposed "SSTS within 100 feet of a watercourse or a DEC wetland,
Proposed SSTS design now greater than 1000 galloasiday or SPDES •Permit required.
�. _Proposed, SSTS for a Cowmerciatl:I►rojcct.
It is the responsibility of the design professional to provide the above luformation prior to soil testing. The
Departutent will determine the WCDEP project status (Joint or Delegated) based on the response, If you
answ'ered,yes to arty of the questions, NYCDEF must witness the soil tests:. This Departrocut will coordinate a
mutually suitable time for field testing witb.the Design Professional and V'!'CDIEP,
If it project has been determined to be Delegated based on the above response and then subsequent
information indicates NYCDEI' is required to witness the soil tests, it will be the sole responsibility of the
deaign professional to schedule re- witnessing of the soil testing with NYCDEP.
!
.............. OR praCl 'T"Y USE r<7NLy
Co wMlydTS;
4 rteo rotcr;t_r !:raotyv EnvironmonvAl Wasrth WT) 278 -6130 Fina (245) 379_7031
Water Suppiy Section (845) 225.5186 fax(845)225-3418
Nursing Services (845} 78.6558 F'ux (845) 278 -6026 WIC(845)278-6678
)Hurting Home Cart hax (845) 27$• W
Early Intervention /Presehool (845) 27WIa FaK (845) .08 -6648
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner: T /iV Address: �
Located at (street): �� �%��� Section: 77 Block Lot
Municipality: )P WRM Watershed: A&..4)
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre - soaking: Date of Percolation Test:
Hole No.
Run No.
Time
Start — Stop
Elapse Time
(min.)
Depth to water
from ground
surface (inches)
Start - Stop
Water level
drop in
inches
Percolation
Rate
min/inch
1
2
3
A
4
1
..
2
4
5
1
..
2
3
_..
4
5
1
2
3
4
5
Notes:
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test 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 hole.
Form DD -97, pg 1 of 2
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE HOLE NO HOLE NO HOLE NO HOLE NO
G.L. )5' /,,. Z '
0.5'
1. 0. 77,
2.0-
2.5'
3.0- 91
3.5'
4.0- --74V) SW lo IL
4.5- -(!Qd1Y69f
5.0'
5.5'
6.0'
6.5'
7.0'
8.0'
8.5'
9.01
10.01
Indicate level at which groundwater is e . ncountered AIOIVP--
Indicate level at which mottling is observed /l/A
Indicate level to which water level rises after being encountered YV14
Deep hole observations made by: Z Date
Design Professional Name:
Address:
Signature:
Design Professional = Seal