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Home My WebLink About3838DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -3 -8 BOX 30 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES FOR. ASE TREATMENT SYSTEM REPAIR - _ — .. A- Internal Use Only PERMIT #/A - -;I k Z– I Z U LJ Repair Permit issued in last 5 years 16 Not in Watershed ❑ 0 Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION % TOWNS,,,„ Z :; //� TM # ., 12--3 OWNER'S NAME `` �i„i' L,�n ��. ar PHONE # MAILING ADDRESS 2-- /3 r, ,e•, J, TO 40-LI ,, iop fir•, /' /P i. APPLICANT � C- Name & Relationship (i.e., owner, tenan ' bnTactor) ` DATE Z ? lZel 2, FACILITY TYPE 5 l S PCHD COMPLAINT # PROPOSED INSTALLER e.–ye IA , X. — PHONE # g6K --( L,% ADDRESS 2 j1 r� v�r �i .Jf��Ur't IpiTA:n� a�9 fLSz -� REGISTRATION /LICENSE # ,AQ Z ? 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. C'mcor k. �- ✓� L i /, « -C- l ,�i� .-- Ri,. i �c fry k �16 be 41sfd (P,,( "3'r e ,i_.. ♦ I T7 J IQ'ti t17 i ✓ r t,: , /1 _. _ / %m. T. C / f7vi aF na Ml 10111Z mo- I, as owner,agree to the conditions stated on,.this form �,`6 j �,�� I, 41,1 Cw^ �� SIGNATURE TITLE G %yvvE– DATE / Z ` ? -Z d- 21 (owner) _ ._ _ .. __. _. i thy =sept c•Ir�irlre , agree t;,. curnpiy Zvi +h. the.conr!itiens.of..this.permlt for the septic-system repair .. SIGNATUR f - TITLE - , DATE 12 - J._2U'!Z. (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. m i Cnnru. uor- vnL- r Pro I Approved Proposal Denied ❑ Ins or' i ure &Tie 121101 I7r + Date I Expira on ate e air o i in compliance with a Ilc , le codes Yes ❑ No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 I JOB '*yx ARROW EXCAVATING, INC. SHEETNO. f .41 Fx-AVm:ef±:f-*8l JRT PqL�AjED B � DAT-E/Z-R*Z'C'iZ--- 4-:4-3EIN Ett4tC=-:� - - �-3 3 A4 L DATE 2- CHECKED BY- _z- jt�,no vlo-es Li,:. tk -"'ex Qtfi iuy Jo SCALE Ic 0 Hw;ffl� 0 e .. ........... . ........ Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Final Site Inspection Date: 1A " L Inspected by: - DL Installer: Arr6tu Street Location: Lo Owner: Ce r z :,r - Town: Q Repair Permit - TM.#i - 1. Type of System: Conventional 0 Alternate 0 Comments:. 1 �. ec 2. Septic Tank Yes No N/A Comments a. Septic tank size 1,0 0 1,250 ... other ..... j. xi�t r jot L LOA b. Septic tank installed level ............... • ...... -; c. 10' minimum from foundation .................. `L X, �r� oZa X01 d. Distribution Box i. All outlets at same elevation (water tested) ... , ii. Protected below frost .................. :........... iii, Minimum 2 ft. Original soil between box & trenches e. Junction Box -properly set ........................... f. Trenches ✓ i. System. completely opened for inspection ii. Length required Length installed [ iii. Pipe slope checked ... ............................... iv. Installed according to plan ..................... v. 10 ft. from property line - 20 ft - foundations ... ( VG- �n vi. Size of gravel 1/4 - 1 '/z " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... __._._ .:.. -vin.- En_ds, capped 9. Pump or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per a roved 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: e, $ insV� k W�� %I-Z0 z` t I �r\ . L 11 �,�� a h �. fc, � I�SI Rev- 011312 JOB ARROW EXCAVATING, INC. SHEET NO. OF 15 AVALON COURT �£AT. . , ..•.. �....�. _. . 'UM) 121 -456 (914) 52iS -4395 CHECKED BY DATE PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES�� r PROPOSAL-FOR-SE-WAGE TREATMENT SYSTEM _REPAIR _.._ .�.._..._.... "..__...._ ._. _...��.� ,..tea.. -.-� -� — - e YES NCY Internal Use Only PERMIT # ❑ Repair Permit issued in last 5 years 9 of in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ?Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ .Joint Review SITE LOCATION a 1pjr<�5O (L Sfif'ee.*-TOW N OWNER'S NAME MAILING ADDRESS %" TM # 'R 3, Ia" 3° PHONE # aC/ Al l I t>S 7:)- APPLICANT 6W f-1 Q r Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE QeSioQ ,ac�,j,4'CHD COMPLAINT # PROPOSED INSTALLERRQSiCQvoAS NNO C PHONE # ADDRESS p REGISTRATION /LICENSE # 113® v Proposal (include a separat �c locati g 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 I, as owner,agree to the c n ' ' stated on this form SIGNATUR TITLE DATE (owner) - : I � rce septic n tame ,: ee tP amrii with: the conditions_o #.this hermit iQL therseptic syst rza.reoa�r- .� SIGNATURE &Ltuo _ TITLE 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. INTERNAL USE ONLY Proposal Approved ❑ Proposal Denied ❑ Inspector's Signature & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUTNAJAt CONITY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSbWACE SEWAGE TRATI ENT SYSTF-MI Owner:. L -6 1-created at (stree8): _ [I unfeipality: Date of Pre - soaking :_ �- D(ook s address: Tit''( 4 Section: B[ocic 3 Lot Watershed: SOIL PERCOLATION- TEST DATA Witnessed by: - Date of Percol-atian Test: Role No. Run No. Time Start — Stop Elapse Time (min,) Depth to water from ground surface (inches) Start- Stop Water level drop in inches Percolation bate min /inch 1 I I- 2 I 2 3 j I. 4 � I I 1 I I 2 3 I I 4. s I Notes: 1. Tests cc be repeated at same depth until approximately equal percolation races are obtained at each percolation rest, hole. (i.e., < [ min for 1=30 min/irich, < 2 min for 31 -5(J min inch}. All data to be submitted for review. 2. Depth measurements to be made from top oC hole. Form DD -9 i, p� TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # HOLE # _ HOLE # HOLE # HOLE # G.L. . 0.5' 1,0' 2.0' 2.5' i3 ro w n 3.0' AA V 3.5' L�c�1`` 4.0' 4.5' of r' w 5.o' 5iZes 5.5' r.Irs 6.0' 6.5' 7.0' 7.5' 9.0' 10.0' Indicate level at which groundwater is encountered IVLA I . Indicate level at which mottling is observed &A � Indicate level to which water level rises after being encountered Deep hole observations made by: t &L Date I Design Professional Name: Address: S i pature: Design Professional = Sea]