HomeMy WebLinkAbout4091DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.72 -1 -38
BOX 31
jig
IN -T
r- "
. kQ
sell
NMI
I
A
1.4,
i
IN
IN
IN
ION
N
IN
ism
I
jig
IN -T
r- "
. kQ
sell
NMI
I
A
1.4,
i
IN
IN
04091
■
■
`I
PUTNAM COUNTY HEALTH DEPARTMENT �' ��
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
`NO Internal Use Only � PERMIT #:�. s.rj6-
D"O"
Repair Permit issued in last 5 years ElliNot in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. L1Q Delegated
l Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
OWNER'S NAME
MAILING ADDRESS
APPLICANT
TOWfJGf� �' , •? TM # 7_L
'r3a
PHONE # J 0Y-975 - T;V9
n,4� v
Name & Relationship (i.e., owner, tenant, contractor)
DATE g*' Al j e/ FACILITY TYPE PCHD COMPLAINT # �� Z
PROPOSED INSTALLER _� C�.�� PHONE #
ADDRESS J0� eW�_ (' REGISTRATION /LICENSE # _ 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.
I, as owner,agree to the conditions stated on this form
SIGNATURE
(owner)
....:I, the septic
TITLE t" ,
DATE
ditions of this er mir for the septic system repair
SIGNATUR TITLE i!'ii c 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 backfill�d until authorization to do so has been obtained from the Department.
C INTERNAL USE ONLY
Proposal Approved Q Proposal Denied ❑
2. 2 / S
Inspector's Signature & Title D e Exip1ratiofi Date
ReDair DroDosal is in comDliance with aDDlicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
LN
Oo
v
h T �'
Sheet l of_�
PUTNAM COUNTY DEPARTMENT OF HEALTH
-- - DIVISION OF_.ENVIR.ONMF,N -T,AL IEA'dLIL•SER_.VIrFS. "
FIELD ACTIVITY REPORT r
ADDRESS: Id, t�iiAo „, tlal('
Street Town State Zip
PERSON IN CHARGE
OR TNTF_R_VTF.u1FD: j: %jbei' Date•
Name and Title
TYPE OF FACILITY:
FINDINGS: 4 �e (Scease� lL
Signature and Title
RFPQRT RFrFTVFD RV:
I acknowledge receipt of this report: SIGNATURE:
02/96
Rev.
Title:
Putnam County Deportment of Hamitic
Division of Environmental Health Services
SSTS Repair - Final Sib laspectdom
lhspwte4,b : Installer: CCR
Date: Ze Lly /Z ; _Q, lz� T-M C.
cat Location:' der: 1.
Street. :-. — - - I I.,
Town Permit 9: TM
R. Type of System: Conventional 0 Alternate 13 Comments:
2. a Tank Yes No N/A Comments
. Septic tank size — 1,000 ... 1,250 other .....
iss I / I
b. Septic tank Installed level ......................
c. 10' minimum from foundation ..................
d. DkIdbudo,fin
1. All outlets at same elevation (Water tested) ...
ii. Protected below frost .............................
.-. iii. Minimum 2 & Oriainal soil between box &
i. System coMletely opened for inspection
ii. Length required Length installed
iii Dina of ' r1spele-PA
iv. Installed according to plan .....................
v. 10 &from property line —20 It —foundations ...
vi. Sim of gravel % -1 V2 " diameter clean .........
Yfi. Depth of gavel i.n-trench 1,2" minimum .........
viii. Ends capped ...................................
Pump or
L SSTS Am knead as per approved plans
b. Fill section — ,
c. Distance Blom water course/wetlands
4. Overall WorkmanWO
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
a. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SETS area .........
• g. Erosion control provided ............................
Additional Comments:
RFSI Rev- 011312