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BOX 29
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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
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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.
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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
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E
Ir.s pecicr'.. Sinna.Lre Q T:tle DciG
Appcirttm3nt Date: Tirne:
J
;{wexcel:Sepfic