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Home My WebLink About3962DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.57 -1 -66 BOX 30 1!%6 ,i ■ ,.k, J6 lys LL jr -L 03962 PuW Health Director DATE: -- . -- - - tORET A � MO MARI -iLN.,'M.Sx. • -- — T -- Associate Public Health Director Director of Pattern Services DEPART OF HEALTH 1 Geneva Road - •Brewster, New York 10509 REQUEST FOR FIELD T_ESMG . Res S ATTENTION: a JOSEPH PARAVATI a GENE REED -'A ",%III �' All information below must be hift completed prior to any scheduling. DATE: In-1-1 ENGINEER OR FIRM: Qr�n ; Ss�rtFSC��a �� -i a� c� PHONE #: REASON: DEEPS: `4 . PERCS:)o PUMP TEST: ❑ ROAD /STREET: TOWN: 9�"u"�Yl �� V l TAX MAP#: '00-3,r3-M-('0(0 SUBDIVISION: LOT#: OWNER: NYCDEP CRITERIA FOR JQ11VT REVIEW AND RTMSSING OF SOIL TESTING YES NO ❑ .. 0 Proposed SSTS within thedrainage basin of WestBranch orBoyds Corner Reservoirs. .. —.- .._..-Proposed SSTS within 500 feet of a rwarvoir, reservoir stem- ©r control lake. - ❑ ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ ❑ Proposed SSTS design How greater than 1000 gallons/day or SPDES Permit required. a ❑ Proposed SST S for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department win determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered j!M to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate aanutually suitable time for field testing with the Design Professional and NYCDEP. If a project has been determined to be Delegated based, on the above response and then subsequent information indicates NYCDEP Is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule m- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY (MLDTEST) AOCI 0 I)Vrf? Homeowner: David and Joanna Tryk 131 Tanglewylde Road Lake Peekskill, NY 10537 Town of Putnam Valley Tax Map: 83.57 -1-66 Installer: Philip Leonforte (License #1022 Precision Excavating Inc. 3 �ochambeau Road Garrison, NY 10524 (845) 736-0571 ) .� . ref Sr 4: Description of Repair to System:, Installation of 72' of Inflltratol§ With 11/2" Washed Stone 4 ' 1 Installation Complete: 11- >2 -14. Scale: 1" = 20' Legend: A -1 =12' B -1 =18' C -2 =29' B -2 =12' C =3 =31' B -3 =19' viol( O k 1.. a: :n �i i �a Putnam County Department of Health Division of Environmental Health Services /SSTS Repair - Final Site .lnspection . IMP -- . _ _ Date: % / �" Der by Installer: G/ t !J�- Str-cet.Loca .. _ L31 l.ah I Town: ,1�ilG V Ilr Repair Permit #: 1 Z -2 �&- -/ �/ TM # jm 7 - c `� 1. Type of System: Conventional U Alternate U comments: 2. Se tic Tank Yes No N/A Comments a. Septic tank size -1,000 ... 1,250... other.. .. . b. Septic tank installed level ...................... ... c. 101. minimum from foundation .................. d fr bu o x i. All outlets at same elevation (water tested) .. . ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches e. Junction Bo = properly set ........................... f irrikehal _. i. System completely ened for inspection n. Length mpired Length metalled - o iii. Pipe, slope, checked ... ............................... iv. Installed according to plan ....:................ ` v. 10 ft from property line — 20 ft — foundations ... vi. Size of gravel % -1 '/2 " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... viii. Ends capped .... ............................... Systems 3. SNdem AM a SSTS Area located as per approved plans b. Fill.seddon- c. Distance from water course/wethmds 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: RiFSI Rev - 011312 •J A� �• �zt�N�4'��_ ✓ o PUTNAM COUNTY HEALTH DEPARTMENT �._' DIVISION OF ENVIRONMENTAL HEALTH SERVICES l ioR�i?' ,SAL FI;.'Fr SEWAG TR- ATMENT:_ SYSTEM .REP�I Internal Use Only PERMIT V Repair Permit issued in last 5 years M Not in Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated LT Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT . DATE \o - \` \— A FACILITY TYPE I PCHD COMPLAINT # PROPOSED INSTALLER P!'E�t'nS iorl � �, �,, , 71— PHONE # rjy�I31p ADDRESS � rnr�� , C� `anREGISTRATION /LICENSE # a iw 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 rep ' . I, as owner,agr the conditions stated on this form SIGNATURE �,..� TITLE Oy DATE (owner) _ I, fhi septic installer, ee f tl omply t "' 'conditio s of°t is permit fio� th-eseptf system repair- - � -- _,.•w. SIGNATURE TITLE r � DATE (Installer) Proposal aDDroved 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. Mutcnuw1 11ee nut v n\ 1 LnnAL WJt W. ■ Proposal Approved Proposal Denied ❑ l _, - z �_— /// zf 1d In or's Ignature & Title Dale/ xpiration Date Repair proposal is in compliance with applicable codes Yes No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 h. -.'N' ,M� -.t t. ... +.;�Y:.wT I� ^YLm -� � ®I�iT'Y�IART�IENT�tOE-�A�H`° .� a .a•4 i.•.•Y.'._ .. S/+ .L �_ �.'y. DIVISION OF ENVIRONNMNTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE °TREAT `SYSZ'EM Owner. _g I Address: Located at (street): TM # 43, S--7 Mouldpauty: a , � 1 -0,4 watershed: SOIL PERCOLATION TEST DATA witnessed by: Date of Pre soaking: Date of Pendatlon Test: B 1 I 1 I� 1 -II 11 I I 1 min. M�M `Ila! / I / e , Notes: 1. Tests to be repeated at sense depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min/mch, < 2 min for 31-60 adn/inch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Forth DD-97, pg 1 of 2 I RIO A raa ARM Arm DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # 0 HOLE # HOLE i' HOLE # HOLE # 0.5' S 1.0' 2.0'��^ . i 2.5' 3.0' 3.5' 4 '4.0' 4.5' —� 5.0' 7A' 7:5' 8.0' 8.5' 9.0' 10.0' dicate level at which groundwater is encountered Ayk -- .._...� Indicate level at which mottling is observed —A A)A-(-- Indicate level to which water level rises after being encountered Deep hole observations made by:, Date lj�JVr Design Professional Name: Address: Signature: Design Plrofessional's Seal Revised July 2013