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03779
\n\ V 3 PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICESGI `
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES NO Internal Use Only PERMIT #
U Repair Permit issued in last 5 years �L l Not in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. l9d Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION de 6 , (.6 EA-r Ltl(, TOWN f Vrr"&,,1VA CC y TM # ?3 , , % — 4.�t,
OWNER'S NAME C- ; C ,q �, f., �;� PHONE # qV!�— 5',Xg- CJ Ca5
MAILING ADDRESS g-r- ,id --J5
APPLICANT WARA
Name & Relationship (i.e., owner, tenant, contractor)
-^ T -
DATE FACILITY TYPE 9;,;5 PCHD COMPLAINT # _
PROPOSED INSTALLER /7�,V-14 . PHONE #
�U?W op S C- y1- 4A- 4 fJ I Frio r7
ADDRESS V A. q f,1 REGISTRATION /LICENSE # !G
Pro osal (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.
&F =LAC -C S �,0 r -r 1---4 t-t h 4- F I E- i- !1C . +A-t 19 40- 04
Jr 5� &�re0 Zf-ec 1
I, as owner,agree to :tie co i ons�stated on IN form
SIGNATURE: ? TITLE DATE
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE >v-ti{' ,°' TITLE; r -... -.... DATE _ . _ ... .
(installer)
Proposal approved with the following 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 backfilled until authorization to do so has been obtained from the Department.
IN 1 CHNAL U= UNLT
Proposal Approved Proposal Denied ❑
6
Inspector's Signature & Title D dJ4 l5kpiratfon Date
Repair proposal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Slice t__ of____ -
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL- IiIEATLII SERVICES _
FIELD ACTIVITY REPORT
NAMF: Tel:
A DI)R E -S LOm 1 ,` //� � � Lavt � 1 '.s i i/c:: / /"�✓
Street Town State Zip
PERSON IN CHARGE
Name and Title /
TYPE OF FACILITY :
FINDINGS: Lrr z.. 1'rezj
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Signature and Title
RFPnRT RE(• E.TVET) BY,'
I acknowledge receipt of this report: SIGNATURE;
02/96 Title;
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Signature and Title
RFPnRT RE(• E.TVET) BY,'
I acknowledge receipt of this report: SIGNATURE;
02/96 Title;
Rev.
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DIEPAB'TMFNT Of HEALIVI
Putnam County Department of l lmfh
Division of Environmental Health Services
SSTS Repair — Nnal Site In Lion
Date: �g/.��/ Inspected by: C ` Installer: 4/1; .,11I
Street Location: :Zri G .'leer l :,, Owner.. _ - ._... .
S"
K ` Towta: v� Seri r air Permit #: 7Z / ci - J L TM #
x. Type oI bystem: (ADVCHUOnal U Alternate U COMMents:
Z. Se tic Tank
Yes
`No
N/A
Comments
a. Septic tank size 1,00 .1,250 ... other .... .
b. Septic tank installed level....... ...............
c. 10' minimum from foundation ..................
d. Distribution Boa
i. All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
r
iii. Minimum 2 ft. Original soil between box &
trenches
) ��
C
e. .Yunction Box — erl set ............ ...............
E. Trenches'
i. System complqtely completely opened for inspection
ii. Length required 3;;L Length installed 32
iii. Pie sl ' e checked ........................ :..........
iv. Installed according to plan .....................
v. 10 ft. from property line — 20 ft — foundations ...
vi. Size of gravel % -1 '/Z " diameter clean .........
vii. Depth of gravel in trench 12" minimum ........,
vin. Ends capped .... ...............................
g. Pumg or Dosed S stems
AMA
7—
3. Sewage 19m Area
a. SSTS Area located as per a ved 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:
RFSY Rev - 011312