HomeMy WebLinkAbout3916DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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83.20 -1 -20
BOX 30
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES Is-0
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PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
'ES N Internal Use Only PERMIT # , , � 00'3
❑ epair Permit issued in last 5 years Not in Watershed
❑ epair within Boyd's Comers, W. Branch or Croton Falls Res. 11 Delegated
K�ReDair within 200 ft. of a watercourse or DEC - manned wetland ❑ Joint Review
SITE LOCATION 'L'I v f �1'11 TOWN Jftp'►n V� �t, TM# 93.120-1-20
OWNER'S NAME So PHON�E # I3 2 +6 501
MAILING ADDRESS ff asar v� v<J a � `O 06
APPLICANT '(>>°N t ew t F LVL
Name & Relationship (i.e., owner, tenan , contracto
DATE FACILITY TYPE �aw► PCHD COMPLAINT #
PROPOSED INSTALLERS �o Ckl PHONE #; VS (6f o >- 3 r
ADDRESS f w G 6,a tr dREGISTRATION /LICENSE # /0)- ?j
Proaosal (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 Went of the repair.
ek -� F
I, as owner,agree to the conditions stated on this form ��� 1 1r�� 13 ce J
SIGNATURE TITLE l DATE
(owner)
I, the septic i stal r, agr e c comply ith the conditions of this permit for the septic system repair
SIGNATURE TITLE IAi 0'0—r DATE I fi
(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 til authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Prop sal Appr Proposa Deftd
n�c.a�
lr�s'pecloes Signature & Iltle Dats Expiration Dat
Reoair Droposal is in comDliance with applicable codes Yes ar / No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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Putnam County Department of health
Division of Environmental Health Services
SSTS Repair — Final Site Inspection
Date: ( Inspected by: i< Installer: Lco C.,, I 6-
Street Loca ' n: Owner: e, Son
1?epairPermiV#:
I. Type of System: Conventional O Alternate O. Comments:
2. Se tic Tank
Yes
No
N/A
Cornments
a. Septic tank size — 1,000.:. 1,250 ... other .....
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
d. Distribution Box
i. All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
iii. Minimum 2 ft. Original soil between box &
trenches
/
V
e. Junction Box — properly set .................. I........
f. Trenches
✓
i. System.completely ppened for inspection
ii. Length required Length installed i'jQ
iii. Pie slope checked ... ...............................
iv. Installed according to plan .....................
v. 10 ft: from property line — 20 ft — foundations ...
/
vi. Size of gravel 1/4 - 1 % " diameter clean .........
vii. Depth of gravel in trench 12" minimum .........
- viii. Ends ca ed ..........................
g. 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 Co ents: rr jj
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01/18/2013 18:88 FAX
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0' - = Soy o Comm, W. &Vmh or Grolm Fda Res, 0 D04AW
Q ❑ Aepo aoo tL at a watwMrse a QEGmdpped wOMM 0 Joint aaule
la 003
$ITH LOGATION 7 1 TOWN +Rrh (1 TM
OWNER'S NAME &fVd%&4 G94=401 PHONE � rjr'�
MrAIUNG ADDRESS J' �#;,
APPLICANT ._.�L-)tZ3
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Nme a IReieltlonsW.a., owr+er, wtva. oorthracfot9 — -
DATE i!a' // ' ! FACIIJTY iYPS F,.gr( TPCHO COMPLAINT #
PROPOSIX INSTALLER { �4G.�'� �,� �1�l a�N�r.� PHONE IV S f f � g`
ADDRESS r.�li�+ REGISTRATION /LICENSE �
asa (Include a separate sketch locating the muse, Property lihee, all edjacenf tarell,i: wlthln 200
feet of repair and the I g srsc! pray; uwd sysum) .
NOTE: The Department may require submittal of proposal from Aoonsed professional depending on the
re wO wftnt of g'tA Me i
I, as "nar,dgres to SUW on
S]GNATUfit 1 ipATE
(�r�9
1. the , agree to cor jpty with a cnnditioris of thla permit for The treM syattn repair
SIGNATURE TITLE l6a% -/f~—' DATE �l fls 1/ 3
Onatanory
uqw�vglh �nndltiorrs:
1. ftwremem of any Ton. Permit, If applicable.
2. Sutmcisaion of as bidet repair sketch by the septic system ftnftt yr ihin So days of the repair, in dt ovate shoW g:
a. Ownet3 mme, Slur Street Alsace, flown and Tart tup number '
b. location of installed rampunetrts tied to M fond pdnis
C. System desot00h (erg.. 1250 gal, Go +a septic t w*. em.)
d. lraslleW name and phone m nher
S. SYt,t M ttimir to be pert mW In''�'bawrdAnce with the atmue proposal and cotxlitlocis
4. The proposed SST'S repair Is considered a teat tit design and there is no guarantee W ace duration at which the
aompmw SST& repair Valli funo#o»-
S. No competed Work is t4 be bm*Med va aufte ion to do an toes been ohtslned t m the Department:
INT914NAL URS ONLY
Approved Q Propose] Denied ❑
Date
In
COPIES: PCHD; Owner; Installer
PC.AP WML
Rau. 2/07
13
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PUTINAM COINTY DEPARTMENT OF HEALTH
D -MSION OF E ROnii IENTAL HEALTH SERVICES
DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEiM
owner:. v�
Address:
Located at (street): T•iV>( 4 �3 2n
Section: _Block � Lot DLO
t1%4 Unicipality: ' A A(1.0-,, W Watershed: f
SOIL P.ERCOLATION TEST I}ATA.
D ate of Pre -soa king:
Witnessed by: •
Date of Percolatian Test:
I Role iNo.
Run Rio.
Time
Start —
Stop
Elapse
Time
(min.)
Depth to
Water from
ground
surface
(inches)
Start - Stop
`eater
level drop
in Inches
Percolation
Rate
min /inch
1
I
2
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3
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2
3
{
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1
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1. Tests to be repeated at same depth until approximately equal percolarion rags are
obtained at each percolanon test hole. (i.e., _< I min for 1 -;0 mirn/inch, <? min for 31 -54 min ,'inch).
All data to be submitted for review.
3. Depth measurements to be made from top of hole.
Fn nn DD-9i.k: ;>r'-
TEST PIT DATA ,
DESCRIPTION OF SOILS ENCOUNTERED IN TEST DOLES
DEPTH HOLE # \ HOLE # _ HOLE # �J HOLE # HO #
G. L.
0.5'
1.5' o�&
2.0' S n
2, 5'
3.0'
3.5'
4.0' �.
4.5'
5.5'
6.0'
6.5'
7.0'
7.5'
8.5
9.0'
10.0'
Indicate level at which groundwater is encountered 0ON e .
Indicate level at which mottling is observed e
Indicate level to which water level rises after being encountered
Deep hole observations made by: P&L- Date
Design Professional Name:
Address:
S i zaature:
Design Professional = Seal
e ,
y_. =..: PUTNAM-00UNTII` HEAL��fi D�P�4RTIVlENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE
All information below must be fully completed prior to any scheduling
SITE LOCATION 1 ���� f`' l 1 TOWN VJAVkrA IM # 133- Z0' - l
OWNER'S NAME ~� Q Sc�l1 HONE #
MAILING ADDRESS
PROPOSED CONTRACTOR /INSTALLER LocA &, ?(.A PHONE # 52-C-24-7(
9
ADDRESS �� �� LA V\ 4t REGISTRATION /LICENSE # I
Reason for exploration: ��X 52 P-0-7e(
ilur to surf e O ack -up in house ❑ find limits of system for repair ❑ other (explain below)
05, +tvt �„p TES
FOR COUNTY USE ONLY
L�c r
�1A I u A,
re & Title Date
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Appointment Date: Time:
kly:excel:septic