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SITE LOCATION
OWNER'S NAME
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
Internal Use
Repair Permit issued in last 5 years
❑ 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
l 7- A 2G1� l y 3-72400-93, `74 _
MAILING ADDRESS
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PHONE #
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APPLICANT � � �i ONO A a Cop 0 t / 14 — ®wl\16l
q %Name & Relationship (i.e., owner, tenant, contraontP`
DATE / �" / / d� FACILITY TYPE 4-601t466- �pP�1 �, PCHD COMPLAINT #
PROPOSED INSTALLER 1� oG�� � PHONE #945' 3C?
ADDRESS IJ/ lf,},y( �1 /}LL --�j�I EGISTRATION /LICENSE # r�R
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 trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
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I, as owner, or r / o t of o ne gree o the conditions stated on this form
SIGNATURE ,/ G�' f TITLE L9 Wh1F-IZ DATE Zo
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditions.
Pro osal Appr ved Proposal Denied .?OKL�6( — 7
I pector's Signature & Title _ AVK_ Date 11
( ) ( ) (Installer), 9 (Applicant)
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COPIES: White PCHD ;Yellow Town BI ;Pink Installer , Oran a licant
PC -RP 99ML
Rev. 8/05
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_ PUTNAM COUNTY DEPARTMENT OF HEALTH
- _ .. - -.DIdISI �N O't EN�YIr;MEhN x � L-HEALTH; SV d . _ .
FIELD ACTIVITY REPORT 06-1-07
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Street Town State Zip
PERSON IN CHARGE /fl7 /'/�!�7 / / !? ]� � ^�
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Name and Title
TYPE OF FACILITY:
FINDINGS:
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I acknowledge receipt of this report: SIGNATURE:
02/96
Rev.
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM w
Owner Address
Located at (Street) Tax Map Block Lot
(indicate nearest cross s eet)
Municipality �tiA �� lGr Watershed
SOIL PERCOLATION TEST DATA
Date of Pre - soaking Date of Percolation Test
1
2
3
4
5
1
3
4
5
1
2
C
4
1 5 I.
1. Tests to be repeated at same
rates are obtained at each
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
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TEST PIT DATA 2
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
P r. :- A(? E X10:
DE TI1 n. : =`:. ;� ,_
G.L. �i S
0.5'
1.0'
1.5'
2.0'
2.5'
3.0'
3.5'
4:0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
8.5'
9.0'
10.0'
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed Nom
Indicate level to which water level rises after bein a countered
Deep hole observations made by: Date
Design Professional Name:
Address:
Signature:
Design Professional's Seal