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HomeMy WebLinkAbout3756DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.19 -2 -20 BOX 29 03756 L IN I C. -. NN IN 6 ' ,'L I milt � 'I NN - ..� .� 03756 lwxaal F PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'ES NO Internal Use Only PERM ❑ Repair Permit issued in last 5 years ❑ � Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland SITE LOCATION OWNER'S NAME MAILING ADDRESS .APPLICANT _ DATE -4/h, PROPOSED INSTAL ADDRESS Q /) . U t in Watershed Fe-legated ❑ Joint Review TOWN II' TM # jQp allL ! + -X6_hJ 1-iQ A/ PHONE owner, tenant, con r FACILITY TYPE I?cs PCHD COMPLAINT # PHONE # jV7S 2? M7 7 REGISTRATION /LICENSE # %OJ-9 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 th nature and extent of the repair. I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) I; the-septic- installer,. agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE (Installer) Proposal approved with the followin onditions: 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 backfill until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Prop al Approved Proposal Denied ❑ In ector's Si§rdturb &Title / : Date Expiration Date Repair or000sal is in compliance with applicable codes Yes ❑ No. COPIES: PCHD; Owner. Installer PC -RP 99ML Rev. 2/07 D Nav Cou pggrM��r ?pjp _ _ y44 ry November, 2013 I I. A 1 20' 2 581, 4 J '&A? V-T' 4 71'� 5 70'; 6 66 7 61' . i- S I Existing concrete septic tank Concrete WMMMO junction boxes 13 1 38.4' 2 71.6' J to 4 82' 5 63' 6 55' 7 49' A Haklay / Carlson 9 Goldfinch Dr Mahopac / Putnam Valley 1Oft pipe & stone SEP,•T /,C�SaYSTEMS.N�, EXCAVATING CONTRACTORS w .tyndaliseptic.com (845) 279 -8809 Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site Inspection Date: 1 / Inspected -by: Installer: Street Location: y 6 -'Ikt L t�tt Owner: TM# ...... 1. Type of System: Conventional li Alternate ❑ Comments: bit /S 2. Static Tank I Yes /No N/A Comments a. Septic tank size l 0Cj0'... 1,250 ... other ..... / b. Septic tank installed level ...................... c. 10' minimum from foundation ..........:....... / d. Distribution Box i. All outlets at ;came elevation (water tested) ... ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box — *Oro erl set ............................ f. Trenches i. Systeni complctely opened for inspection ii. Length required 9WJ Length installed _., i z iii. Pipe slope checked ... ............................... iv. Installed according to plan hz= v. 10 ft. from property line — 20 ft — foundations ... vi. Size of gravel's: - 1 '/z " diameter clean ......... vii. Depth of gravel in trench 12" minimum .. +viii. Ends capped - . Pumv or Dosed Systems 3. Sewagre S s m Area a. SSTS Area located as per a roved plans Y b. Fill section — ! / , c. Distance from water course /wetlands i 4. Overall Workmanship i a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box ......................... .X . c. Backfill material contains stones <4" diameter ......... d. Curtain drain & standpipes installed according to plan e. Curtain drain outfall protected & dir to exist watercourse i �r f. Footing drains discharge away from SSTS area ......... LJ�'. �vt.rrw•� -- g. Erosion control provided ............................ Additional Comments: -, RFSI Rev - 011312 - P0NI AIM COUNTY DEPARTMENT OF HEALTH I)MSIGN OF ENVIRON INTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM owner:. kr Address: � �o I �l ���� � LetA e Located at (street] � C,11 _.1r LA Lv� —Atl a Tilt # Section Alock t- Lot 'Z O 1" aicipality: �r^� `��� Watershed: �'ll.�✓ T� Soli PEISCOLATIONi TEST DATA ° ne5 witnessed by: � L Date of Pre- soaking: Date of Percolation Test: it g tom. 13 ll 13 13 Dole No. Ran No. Time Start - Stop Elapse Time (min.) Deptl,i to water d onn surface (inches) Start ­Stop Water Percolation level drop ate in inches Min /inch 1 ° 3® t�� ,i*(% 3 3 4 1 2 3 4 1 1 3 4 1 2 3 4 Notes: 1. Tests cc be repeated at same depth until approximately equal percolation rates are obtained at each percolation rest, hole. (i.e., < l min for t -30 minlinch, <? min for 31-60 mitvinch). All data to be submitted for review. 2. . Depth measurements to be made from top of hole. Form MAI,.p?; of'_ Co�cre. e _ _EXCAVATING CONTRACTORS 2(i `Ivy HiII`iZd. Brewster NTY`_1�iI500 ' ($45) 279 =8809} SEP7 /C ST'STEMSime. i I5 ono � f c-1 q, l.ow Pr07° `f G 3 wide q 14 Bai Nov 041310:30a Tyndall Septic Systems 8452795989 P. 1 SHER%IT'A AMLEP, MD, MS, FAAP LORRTITA MOLI'NARI, RBI, MS�F Associate Commissioner ofHau h DEPARTMENT MEET OF HEALTH I Geneva, Road, Brewster, New York i oso4 91-;QUIST FOR --@UID TESTING AL information below must be falls completed prior to any schedul-Ang. Ea rc I EFUR OR FIPIVI; 4 :�E-RSOzv TO COINT 7ACT_ . L-1 NI-KIVI CONSTI RUCTION a PAIR PROGPUM PHONE ROBERTi BOND! ROBERT MORIUS, PE Directar of ErvironmenU31 Health Q AMMON Pp,()G W +ASON DEEPS: 9Y'PERCS_ PUMP TEST: D RO DISTREET: TOWN: C- S J3 l 3 71's Z ® :. 3/— TAX MAP LOT CDEP CRITERIA FOR JOINT RZ7VqRW AND WITNESSING OF SOIL TES L .. -_ _ _ _ ._ ..5^�. _...... _❑ � _ - Opr'Sed S .: ��'Y i:i:I41L { � ttl is ixac ii' l�i"'i��'a7 •YY JWt l}.i��`L• LSi B6ysts co1 3�ei Croton Fats Reservoirs. ❑ ❑ Proposed SS?'S wig 500 feet of a reserrrofr; -,reservoir stem or control lake. O ❑ Proposed SSTS wj&iu 2€31) feet of a watercourse or a DEC Wetiap.d. ❑ ❑ Proposed SSTS design flow greater than 1000 gallonslday or SPD 714,S Permzt required_ ❑ ❑ Proposed SS T S for a Commercial Project rt s �e responsibility of the desl� ps ofessaaizai -to provide the above Wormatioa prior io 50�.f tes-J ��. The Department Will determine zhe NYCDEP project status (J'oiatx or Delegated) based on the response. UIL you answel-ad ►acs to any of the questions, NYCIDEP must Witness the soil tests. This Department will coordinate a nnztuaUy suitable time for field testing with iffie Design Professional and NYCDEJP_ If a project has been deiermmed to be Delegu ted based on 'die above response and then subsequenat fnTormation hadicates t4 CDEF is required to witness the sail tests, it vW be the sole responsibiRity of the desgu professional to schedule re- witnessing of he soil testing vdth NYCDEP- iron COTMTY Vsr" 0MAY B �TF: T�REr COMI MEP ITS. ��_aa_eaarsrrnc :a Environmental Health (94:5)278-6130 Fax (845) 27$ 792i Water Supply Section (84-5) 2-7-5-3-186 Fax (845) 225 -5418 Nursing ServirPs (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 273 -6678 Nursing Home Carr Pa- (845) 278-6085 Early luterven ianlPrescheal W:5)279-6014 Fax(945)278-6648 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES _....... JNEATMEW-S"MM REPAIR i _ use only I�Qi11H'1' jE U GRe4m Ana ,s��r � fi y�aara U Not In WateraW U Q fIlWw min FArM 6:afarr r.. vv- Branca or Ctmn FW Ras n Ddeptad 0 LJ fief rag a-M 2w b- dtawmemts mew DEC -(ltW aet.��.a."d'� Ll JOi RtMaW MTE L0CATN V'A , ia TQWh ' OWNEWSNAME ��l�7li�4N.i�AiK M'+'V"t70,C&$IjW PHONE N,� ��C- !fslas MA L NG ADDRESS ; g- lma&41ad cl !' APmucai±R / U 4� /�A�/ �? r� Ti !_ G/c .>ee C / mray $ %worsw Ilk.. owrw-. r,wrt Cwhadw) DATE .,. FACILITY . Pes PCHD C(3MPL&Jl4Tail PR+OPOSM INSTAI i Eli ADMESS a iD v v. 1 IS rRAT*N,Ml<NN3E # �-4 I �t (irtcktde a eelmte aRMh locetf the house; property tines, all aducertt waft wilmn 200 feet of Malr and the kwlgom of exletlaq and pmpmmd SyMm) NOTE, The Mparir mfil may fewiro toil7rrriftiif cat pmposw front imensW IxotemlonW depoWing cm the nne,mnl C�� repellr r 1. as owner) tC� tit@ •ard' • tarry on MIS farm *8113NAT to , .r yi—i LE DATE i r ►4 (qWF" I, the septic instaTivr swee Io mmr.-Ay with the :ondilivnS at Me permit lo; the Sic system rooair SIGNATURE � T G 5 � OATE % 4 Jj- 3 Prpjru��dp�{'O wI1RUtetel�icrns. � � .. .. . t Prric omant of any T own I ++ut it appeinable. 2. Sutknsslua at as built repay mumn by tW saptic systerl instat*r w-ttw 30 days of the tew, i rr Or�pti�e stut>atirr� a Owners fts". 5ft SOvst Nmn.e, Todar ana Tax Map t-mr0 !r o. Loeatean of inalalled ounipttsnts LW w t&o frAlW ptunte c. Systems+ deemptwn to el , t 2SO gal Cmerete septic: wk sit I d. b"Wkim' naffs and ptrrm rnrmbar 3. $lrstem rmpuir to he perta med in acanr&00 w-1tt the above proposal Ord cvriditlnns s. The pmoosed SSTS repai • Is caraila rod a bent f>f oe5 n and there is no guaMea to the duralion at vdtiraTo the S. No comoeted worfe in is lie liueWgWd urM a tt o!12Ww. to co so has treen obtained from the DeWLmara. _ WTOiALWE ONLY Propasal ,AWmmd 0 + far pwul eemad ImWeckie i Sdgnswre in ctNS pliant, With COPES: PCNO; Owner instxlller PC RP 99ML :)ale D Exom ion Bate Rev. 2M7 Nov 0713 11:35a Tyndall Septic Systems 8452795989 p.1 ,..• . ,. ..., sue.. ua ar .. ,. .. � ..._ �„ .•.rr-v�r ..x5. .�.. ., - .. y . � ....: .. �....... �,...: •ate •.:i .. , _ ^. vrt.n _� e. .. � .. • PUTNAM COUNTY HEALTH DEPARTMENT DIVISION 01F ENVIRONMENTAL HEALTH SERVICES THIS 15 NOT A REPAIR PERMUT PPOPOSAL FOR EXPLORATIf M OF SEPTIC SYSTEM FAILURE All information below must be fully completed prior to any scheduling SITE LOCAT ION qaOA -41 !� -az.- I OW N C TFA 001NER'8 NAME LL�%�1' Co- r Lso in PHONE = k l SLVj 29- gZar IUTAILING ADDRESS Tarn PROPOSED CONTRACTOR; INSTALLER �G( � �� �.�-- — RHONE lid AGCPESSdV Reason for exolora#ior.: 4ncc,co "o��« ❑ failure is surface ❑ back -up in house Vrl find i;:,:�s of sys ern for •repair ❑ other (explain belom) FOR COUNTY USE ONL "JI I i I E Ir.s pecicr'.. Sinna.Lre Q T:tle DciG Appcirttm3nt Date: Tirne: J ;{wexcel:Sepfic