HomeMy WebLinkAbout4151DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.74 -2 -23
BOX 32
04151
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL:- FOR..SEWAOIE TREATMENT SYSTEM REPAIR r ��
YES N Internal Use Only PERMIT #/ '= L'-V 1`""-11-
❑ 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
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
Q .r y.l- ✓T TOWN 4!9, 83 . q-c -23
9,6&L—% Y, C.491,OLL a PHONE # c;b
Name & Relationship (i.e., owner, tenant, contractor)
DATE (- 8-t3 FACILITY TYPE
i
PCHD COMPLAINT #
PROPOSED INSTALLER
511,01-416,,
PI-JiA PHONE # 9 /4( - 7 37' (06�0
ADDRESS ARAD UV
5" PeeK5
1(
Ny (WREGISTRATION /LICENSE # /D 1
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 T e nt:of t ere air.
$.. s e
a
I, as owner,agree to the conditions stated on this form
SIGNATURE Ro4kAk V)ls&AAt%/'`" TITLE !w"'c& DATE I' lo "13
(owner)
9; tht. #pSii laii#r; -agpee to complu`i±rrith the cond:tions.of.tN permit for tizc�:sep;;c s�,:~tem re�►ais -
A
SIGNATURE / �� `�G TITLE �'i °'��'
DATE ,1 l
(Installer)
following ProRQ"ARRaaffld the 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 backfilied until authorization to do so has been obtained from the Department.
iat4;=, Xt�J *41`�WA
Pro al Ap r v I L"J Propo I D ed L i
•- �R X, X47C I
��t%(A1� l lg 1� ll (
Ins is Signature & Title Date Explratlo6 Date
Repair proposal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
�-o
fl,4i;
a�
(A)j
°rig A t I 1) FAX
c 5 A Qic,e. 157'
�a�r P�c�s11�c� ,kjy
ti .4--
F
1 {
P,dp x.5.4
c
i
(a
r
y °?�V� Su�t1LoN(kPp L3 y
1 (914) 737 -6548
• BENNY SINISCALCHI PAVING, INC.
MASON CONTRACTOR • 5 ACKTOPPING
} SEPTIC TANKS
118 OLD BAY ST>=tEET PEEKSKILL. NY 10566
ZOO /Z00'd 6ZL9# ONIAVdI IUSINISANN38 7P. 0bAR1t?IA 47:17 1'1n7/c1J11
P
(o
Ur-
SOY
Tt
•r
ri4 at FNE0
ZOO /Z00'd 6ZL9# ONIAVdI IUSINISANN38 7P. 0bAR1t?IA 47:17 1'1n7/c1J11
t) Z XJ fix G `f `i �C IG 1 "tvi t
�� .� - - - --- C
1-7 � }
I
i
t
r
Aw&'h@A-
fieiv I- rlloat+ y'i C SuRr:o.+fiPp Qi
(914) 737 -W48
FENNY SINISCALCHI PAVING, INC.
MASON CONTRACTOR • SLACKTOPPING
SEPTIC TANKS
118 OLD BAY STREET PEEKSKtU, NY 10566
-T Bax
a C e 1)
+
03 1 D Ir
Z00/300'd 8ZL9# 9NIAVEH81VOSINISANN38 NOV86LOL6 9Z :LZ £L07/RL /LL
r
•
P �
N
I
i
t
r
Aw&'h@A-
fieiv I- rlloat+ y'i C SuRr:o.+fiPp Qi
(914) 737 -W48
FENNY SINISCALCHI PAVING, INC.
MASON CONTRACTOR • SLACKTOPPING
SEPTIC TANKS
118 OLD BAY STREET PEEKSKtU, NY 10566
-T Bax
a C e 1)
+
03 1 D Ir
Z00/300'd 8ZL9# 9NIAVEH81VOSINISANN38 NOV86LOL6 9Z :LZ £L07/RL /LL
+
03 1 D Ir
Z00/300'd 8ZL9# 9NIAVEH81VOSINISANN38 NOV86LOL6 9Z :LZ £L07/RL /LL
Date:.
Street
Town:
Tuna of -QueNim- I
Putnam County Department of Health
Division of Environmental Health Services
SSTS Repair — Final Site Inspection
Inspected * Installer:
Owner: 20_'C_t�� -it 1�5 C 4 1 �CJ I
Repair Permit #: If I -1 3 Tm#
------------
Additional Comments:
RFSI Rev - 011312
2. Septic Tank
—Yes
No
N/A
Comments
a. Septic tank size �OO .1,250... other....,.
v,
II
b. Septic tank installed level ......................
V/
c. 10' minimum from foundation ..................
re-- P-xk
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 ............................
E Trenches
i. System com letel y opened for inspection
ii. Length required dA Length installed N$ I-
iii. Pipe slope checked ..................................
iv. Installed according to plan ....... .............
v. 10 ft from property line — 20 ft — foundations ...
vi. Size of gravel % -1 1/2 " diameter clean .........
-----------
vii. Depth of gravel in trench 12" minimum .........
viii. Ends capped ....................
uiili-oi Dosed Systems
3. Sewage System Area
a. SSTS Area located as per approved plans
b. Fill section — :
V
c. Distance from water course/wetlands
4. Overall Workmanship
V
a. Boxes properly grouted and installed correctly'...........
b. All pipes flush with inside of box .........................
.0
c. Backfill material contains stones <4" diameter .........
V/
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:
RFSI Rev - 011312
11/07/2013 00:1.9 9147394032
BENNVSINISCALCHIPAVING #5100 P.002/002
(molaq uieldxa) aayjo ❑ ateda, Jo} ura4f%s 4o ippwl' asnoy ul do -xosq p awns oI ain11% ❑
o4e�g1 xa,jo} ua�eaa
�SN30i -1/ NOL LVUiSfJIa d ai '� �� �' / SS31�aCb
hib 4 aNOHd -4041 , U 1- !VISNVU0J.3V81N0O CgSQdObd
SS3UCCV MINN
! �� --1c& # 3NOHd '-C -Sva41 o� BAVN S.1QNMO
LEso1 �'"s�,aad Nnnol� -D� -9 -dlV � Nol.�VOo-t�lts
Suiinpayas !wa 01 aold'd pajsj0wo3 1 aq tsnuu mopaq uopwao}mu jrV
3unlr A walsn oudss Ao Rods ao1d9 HOA IVSOdO
.LIW83d -EIMMH V ION Sl SIHI
SSOIAU�S HilVEH Ib.1N:MNOWAN�l AO NOISIAIC
-LN3W1. VclaC Hi-IVBH KLNnOO WMInd
SSH .1a0 /100'd AN iZeislz5vs '111M 7v iMlA13 -WH KVIV I1 1102-1MYR
rk '
1
Y
PUTTNAIM COUNTY DEPARTMENT OF HEALTH
DIVISION OF EIWIRONiVIENTAL HEALTH SERVICES
DESIGv DATA SHEET - SUBSURFACE SEWAGE TREATINIE�vT SYSTIEM
0weer:, CX fro Address:
n G 83.��F rL.
Located at (street): `5 �r 2 TMI Section: _ Block Lot' 2
Municipality: *r�kr Va Watershed:
Date of Pre - soaking:
SOIL P RCOLATION TEST DATA
Witnessed 6y:
Date of Percolation Test:
1 H ole No.
Run No.
Time
Start —
Stop
Elapse
Time
(min,)
Depth to
water from
m
ground
surface
(inches)
Start - Stop
Water
bevel drop
in inches
Percolation
Rate
min/inch
1
�
2
3
-i
2
3
4
I
�
2
3
4
f
4
`
5
,
1
�
2
3
4
Votes:
1. Tests to be repeared at same depth until approximately equal percolation rates are
obtained at each percolation rest. hole. (i.e., < 1 mitt for 1 =30 min/inch, < 2 min for 31 -60 min/ inch).
All data to be submitted for review.
2. Depth measurements to be made from top of (tole.
Form DD-91. o! : or 2
T'ES'T PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
1.5
Indicate level at which groundwater is encountered JZ®N Q-
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered !�-
Deep hole observations made by: _(� L. Date I $ I
Design Professional Name:
Address:
Signature:
Design Professional = Seal