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Home My WebLink About4040DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.66 -2 -5 BOX 31 1 w = +�, IN 1168 -r n f E� FF '� N NINE ' IN 6 �� , ,, IN IN NINE 19 tkc,T 0. %4 '4- % " PUTNAM COUNTY HEALTH DEPARTMENT•D ` SCI ®98gg7�� ry DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROP • SAL FOR SEWAGE TREATMENT SYSTEM REPAIR 1 .:._ _.._ _ _ . _ YES NO Internal Use Only PERMITP-_ 0 Repair Permit issued in last 5 years I-E' Not in Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated M ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION' �7/ IWWrt (t• TOWN VrWj4ALVaLLE TM #9 3,66 -,;1 - S OWNER'S NAME m N�� S LIFIt NZ Q 5'% HONE # 0/091(/ 9Y7- 5'a a y MAILING ADDRESS ,t. cv C " " eI<sA j I O APPLICANT (,v Q t` Name & Relationship (i.e., owner, tenant, contractor) q t� DATE ocs PCHD COMPLAINT # PROPOSED INSTALLER /7'n cv*L_Q 6/tFQf M ( PHONE # s 5'g S' �� ADDRESS �46747 ®SGT WA R 7 REGISTRATION /LICENSE # /0 (J 3 CC( /V7 05-t79 � 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) �;I ==� 13 j' NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. I, as owner,agre to the conditi stated on this form d SIGNATURE TITLE 6U)t4f M1 DATE (owner) 1, the septic instal. r, agree.to- comply with'the conditions of this permit for the septic system repair SIGNATURE TITLE DATE $ l (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 Propos oved Proposal Denied ❑ . ;fro" ►- �- In or's gnature & Title Datk J Ex ation Date Repair proposal is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ul, I&T 7 tA 3, c;2 OXiVe- C(-4kF- PC- rc P,�J,t 1,9 57� '07 Ail V e-� W L9 c/41pt Ce wteHT -r4 CO /'R4-IlMo Tk WAU D ea< 3 3-330 1C- Ll E G 31 OV'06S ;,30 u 7 F3i c;2 .t. -�:l �. r .��r /��. / �� • . r / -I- �•y. .•��4� y.. .�.� ... �Y. J..� ! •V ?Z�w-^��.. •.. .• .�_. +. _. � 1.. . .. r� �H\r �.i"+ �i r. p4e, LqkC OgIlVe C(6p_E PC-,Cje5jA-j.tl) /V 57� ivy /0 Y = Sabs�� tvIV , ds 7 S �g 90--r-r k Ce t4 T- - r4 m (e- Cp i �� Wpu Dr ct4 poi fi fj D- , 6-�7 �C- �0 /6 r 129 31 30 r �-5 �, .!2 .mac lC 3 3 0 tz�c�� -�6��. Ryw�6 'rdKk — m V'o &S 9&4 x -r6t QW k Putnam County Department of Health Division of Environmental Health Services 1 ` SSTS Repair — Final Sitegspection '7 Date: �'� Inspected by: . I ei,! Installer: ��- Stre•t Town: Pa thyc (T Repair Permit #: — TM # 63, 1. Type of System: Conventional U alternate U Comments: 2. Septic Tank Yes No N/A Comments 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 e. Junction Box — properly set ........................... f. Trenches i. System completely opened for inspection ii. Length required Length installed iii. Pie slope checked ... ............................... iv. Installed according to plan .......:............. v. 10 ft. fr om property line — 20 ft — foundations ... vi. Size of gravel % -1 '/: " diameter clean ......... -vii. Depth of gravel in trench 12" minimum _ - viii. Ends capped .... ............................... g. rLimp or osed S stems 3. Suva e S stem Area a. SSTS Area located as per approved 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: RIFS1 Rev - 011312 �❑ ,/ ❑0 ❑ SITE LOCATION OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT K11 ` Svc 9'smeO PV DIVISION OF ENVIRONMENTAL HEALTH SERVICES f ftc I. AS-0 r Internal Use Repair Permit issued in last 5 years Repair within Boyd's Comers, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC - mapped wetland PERMIT L9' Not in Watershed ❑ Delegated ❑ Joint Review IL TOWN �l�nriF- 1 ALL TM #� 3,66 S ye LiElz N �% HONE #9OC/1YVY7 - S9aY ),K t'_ D 61 v $ . LAae O E I <S/< i I I , h! 1 / O5-.� `7' APPLICANT '- L7q Q p 0 pt 1q G 6 2 r Name & Relationship (i.e., owner, tenant, contractor) q DATE 7 j p / FACILITY TYPE 06S PCHD COMPLAINT # 1 "�� ^I�� PROPOSED INSTALLER f)n Wh(tg ( PHONE # s "�� y (47 ADDRESS .�� REGISTRATION /LICENSE # _ .10!V-3 C- c i t /dS 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 I, as owner,agre to the conditi stated on this form 0 SIGNATURE �.l.�u!/ TITLE ()U%NF,6' DATE I, the septic instal r, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE 146, DATE (installer) Proposal aporoved 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 Propos oved Proposal Denied ❑ In or's gnature & Title Datt Ex ation bate Repair proposal is in compliance with applicable codes. Yes No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 _ �- : Pi. J�,' N��a- C4JF� .?N'�`�9E�'�►�.TY�i�i'I "'OF H�.�LTR :�b . - ... DIVISION OF ENVIRONNOWAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: S�yl� -r' Located at (street): Mmid"Uty: ZINO% VC. J .f If Address: TM # 63, watershed: SOIL PERCOLATION TEST DATA Witnesaad by: Date of Prs}*Wft: Date of Perook" Test: ,- ',Molly !' J Notes: 1. Tests to be repeated at some depth until approximately equal percolation rates arc obtained at each pmcolation test hole. (i.e., _< 1 min for 1 -30 mWinch, < 2 min for 31-60 mWinch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Fonn DEM, Pig 1 of Z I 1 •1 1 1. 1 1 II I 1 1 r I I I Notes: 1. Tests to be repeated at some depth until approximately equal percolation rates arc obtained at each pmcolation test hole. (i.e., _< 1 min for 1 -30 mWinch, < 2 min for 31-60 mWinch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Fonn DEM, Pig 1 of Z l I D l Jrl l IPA H A DESCREMON OF SOILS ENCOUNTERED Eq TEST HOLES fa DEPTH HOLE #-j— HOLES HOLE 0 HOLE 0 HC) LE j � •arm: -.' -a,.. a.v.:_ r.. C'� ... . o... .. 0.5' 2.0' �yL, 2.5' r 3.0' A Zn P ` i •. r is i :. l ` � .. 1 4.0' t:. 5.0' 0.5' - 7.0' 0.0' 10.0' Indicate Level at which groundwater is encountered M �~ u My;`: M.&cate level at which mottling is observed A - -- Indicate level to wMch water level Has after being encountered Alfa'° Deep hole obserwitions made by: X404 4 3 Deb : Design Proffessional Name: Signature: Design PmfessionmVo Sad Revised July 2013 7l "ke CPvrKgpa tia ccF�, gy. .......... . Rao ,D pal�� WSJ t_ �D /zoo T,6r4(4( rwe,4(2 ^l l � - - ...y o5 P SovvtP__ 9 4'��W try �� 5595 _ r re.. Yfi" 'QL . . } .. —< '� !"' � �y M -( CG.,w .r � ♦ iT,n►. . .+u{ iY i _'_,L.,!..._...__. N " ' N' L I -- - Orr ... , i I 1 �i • I I 1 , I I - -f C 7 � I I j- it -7, 17,i IL , %- - : , _ I - - I , I4/ 7 , — I i