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BOX 30
03843
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03843
YES NC
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
3POSAL FOR SEWAGE TREATMENT SYSTEM REPAIF
Internal Use Oniv PERMIT #
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Repair Permit issued in last 5 years LW Not 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
APPLICANT Oft) +A 4C JZ4A-
Name & Relationship (i.e., owner, tenant, contractor) /
DATE 9 %d' — FACILITY TYPE r-1'V" PCHD COMPLAINT #
PROPOSED INSTALLER Lora ( CVV ft J90 &" PHONE # 60 Y11610.) -1k .
ADDRESS REGISTRATION /LICENSE # k)OV -1 10.)-2
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
naturp anti axtpnt of tha rannir
W447 /0-dove? l 6 r0A - ,1n, >4
I, as owner,agree to the conditions stated on this form
SIGNATURE !.t TITLE 7!960vi DATE 1Fj I.s
(owner)
I; th Ir: Ins . r, agre,.>e•+ tply with the conditions of this permit for the septic system repair .
SIGNATURE TITLE DATE r
(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 Denied
is in compliance with applicable codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
to
Yes O
Rev. 2/07
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Putnam County Department of Health - Division of Environmental Health Services
SSTS Repair — Fina Site Inspection
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Date: inspected by: _ 'L) Installer: V.7
Street Location: s Owner: 6 au&o "I"
Town:'? V Repair Permit fZ —17p, —1j' TM #
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1. Was System inspected? Ye g- No 0 If not, explain:
'2. Type of System: Conventional 0 Alternate 0 Comments:
3. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size ... 1,250 ... other .....
b. Septic tank installed level ......................
4. Distribution Box
a. All outlets at same elevation (water tested)
5. Junction Box — properly set ...........................
6. Trenches
a. System completely opened for inspection
b. Length required Lengthinstallecv--o—U
rtA J.,)
c. Pipe slope checked ..................................
d. Installed according to plan ....... I ..............
e. Size of gravel % - 1 V2 " diameter clean .........
f, Depth of gravel in trench 12" mirtimum...........
g. Ends capped ....................................
7. Pump or Dosed Systems
V/
8. Sewage System Area
a. SSTS Area located as per approved plans
b. Fill section —
c. Distance from water course/wetlands
9. Overall Workmanship
a. Boxes properly grouted and installed correctly ...........
b. Backfill material contains stones <4" diameter .........
c. Curtain drain & standpipes installed according to plan
d. Curtain drain outfall protected & dir to exist watercourse
e. Erosion control provided ............................
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COPIES: PCHD; Owner; Installer RFS1 Rev - 011916
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Tel, (845) 526-2471
Sep.04.2013 03:03 AM Local Guy Plumbing 8455280781 PAGE. 1/ 1
PUTNAM COUNTY DEPARTMENT OF HEALTH
-, D1V1S1QN OF,ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
rho OM FOR WL0Raj30N QE-qEUIC JXSTEM FALURE
All information below must be aft comPJ1 0 pIOW prior to a ny scbedullng
SITE LOCATION TOWN 41 vyq-flel TM #
OWNER'S NAME D 0 k6 PHONE # 7' 7 2 f Q w Y
MAILING ADDRESS t Q Fl 4.2 I .0 r4r.11T �r. `"�t 1'�'�Nlo ' at
PROPOSED CONTRACI'ORANSTALLER i- 'Q60A' to PHONE # 0 I .C4 41
ADDRESS 1��*►� -V/ REGIS`1RATION/LICENSE# 30- 7.4
RS&M (or r{�tEon:
failarc to surface Cl back-up in house nd limits of system for repair ❑ Other (cxploln below)
AppoixitnMat Date:
Time:
kly 2015
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1-4'� u,
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner: A /I-C/- Address: A Ffo1 -Q4dQ )
Located at (street): TM # k3, D
Municipality: �(tM V � Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by: �� r
Date of Pre- soakingi 9l ! Date of Percolation Test: 1
Hole Hole
No. depth
(Inches)
Run
No.
Time
Start— Stop
Elapse
Time
(m1 °.)
Depth to
water from
ground
surface .
(inches)
Start - Stop
Water
level drop
in inches
Percolation
Rate
min/mch
2
_
fJ- a
.�
3
5,
1
2
3
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.
Fom DD -97, pg 1 of 2
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES.
DEPTH HOLE # �� t HOLE # HOLE # HOLE # HOLE #
G.L.
0.5' S T
1.5' Acm Oe,
2.0'
2.5' t
3.0' k G
3.5' %c
4.0'
4.5'
5.0'
5.5' S
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
10.0'
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: % Da (e
Design Professional Name:
Address!
Signature:
Design Piroffessional's Seal
Revised July 2013