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04158
PUTNAM COUNTY HEALTH DEPARTMENT K
DIVISION OF ENVIRONMENTAL HEALTH SERVICES(` '
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
_ _.....
YES NO Internal Use Only PERMIT #:: ,2 jv
P �-,/ Repair Permit issued in last 5 years LA Not in Watershed
0 U Repair within Boyd's Comers, W. Branch or.Croton Falls Res. uu Delegated
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 2� rr L 9 ST TOWN PV VM ,4 c. -)p TM # 1:3, Z
OWNER'S NAME M ptia % . I-, V t 0 A C PHONE # 3i�r - 5'43 - a 3,��
MAILING ADDRESS '55l AQrV(,s S; (-Ale e45 A- ,rK.SA,) . N 1 1657? '7
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
rK_ s Z76--? S 1�
PROPOSED INS14LL6) ER � <3 PHONE # g /y- g yq- 3kZ7
ADDRESS REGISTRATION /LICENSE # AM
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 an xtent of the repair.
7A 1.4 Lj- z 0 L.7) 5' irl r c r W &a +N / 10e0r4
� f� .4J-K(Y) 330 -� cw-g s wile Stow e.1 tt4 sa.n�
I; as owner,agree to the conditions stated on this form j
�`� e 1kall
9
SIGNATU
R4
TITLE VV DATE L
(owner)
-- I, the septic instal r, agree to comply with the conditions of this permit for the septic system repair.
SIGNATURE .. - . - .. �^ TITLE �C4 �'� - _. DATE .r ' _!
(installer)
i
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.
INTFRNOL IMF ONLY
Proposal Approved Pr 1:1 oposal Denied
/
pest Signature &Title at Exp rat Date/ 6, r/ ,
Repair proposal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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MEMORY TRANSMISSION REPORT
TIFF MAY -08 -201 ! . 03:22p11
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER
139
DATE
MAY -08 03:20PM
TO
85262595
DOCUMENT PAGES
001
START TIME
MAY -08 03:20PM
END TIME
MAY -08 03:22PM
SENT PAGES 001
STATUS OK
FILE NUMBER 139 * ** SUCCESSFUL TX NOT ICE*
�� ��� �� PLJTNAM COL3NTY HEALTH L7EPARTMENT �-V� ������ �
[DIVISION OF ENVIRONMENTAL HEALTH SERVICESKGe ' �(b
QR(3)IP-Q+SAL- FQR SEWAGC✓'6'9 EATNAEPI� SVSB'Epq MJ-=1- RR
O lr.terft,al Use On PEFIAAI'r # -
..- �- -,, /II iaapalr permit Issued in last S years Not In Waters eti
per- 1 Repair w tnin 9eyd•® Cpmerft. W _ BraneT er. Got4 Faller Res. Mr Oeleamt @d
Isl pa r with.n 200 It- of a watarcourso or DEGmnpped wetland Joint Re1/iaw
SITE LOCATION 3� �ti[_C' SJ' TOWN is Q'Pi.4 Gf�-� TM p !Wn. ZS00— a 3�
OWNER'S NAME . A(�.t,A- Z-- VI i co 44 L- PHONE # 33'' - S't?3 -- Z23
MAILING AoORE s S �-$ S l
APPLICANT ��ii rw/i4�o ��.C46 �,.2 -lr
Name 8 Relationship a.m.. owner, tenant. oontractor)
(,,��RFIICJIPCISSIEC) TYPE COMPLA T # '' iN� �ALL ov-=o G T PHONE # cS /y- +F y•g— 'r�SYSi�'
m SG A a✓' v -ge�YS
A17LaF .ES6, ^_.,;�.�s!`_►- ,i:'!�` �J✓4- !- C.,>rtr� �Y,' ,REGISTRATION /LJGENSE #
Pr000sal (ertdude a saparata sKataly 10,r01tinp tlta I'tous ®, property lanas; weals; wif t7tV'n 2.00- ^ " "' •^- --
Teiet oxf repair and teta loaatlon or axisteng and proposed mystem)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature any9 xtent of the repair_
�l..rs �. Graf► - r .o --n _�'� r ^� r psi x.c /IC u i,wA._tx w ie9 ...s �.4 -C . A _.$ c
1, as ownar.agre�%e,(to th e�oncl ci ns strted on th s form ,
SIC3NATU�IIN i[w V L TITLE MATE 4E;4-
fov —)
1, the septic Instal r, agree to comply with the conditions of this perm�iitt� for the septic system repair
SIGNATUR
(Installer)
'i - Procurement et of arty Town P mit
er. It applicable- '
2: Submiaslon of as built repair sketch by the, saptic system installer within 30 days or the repair, in duplicate showing:
a. t?wner's name. Site Straat Name. Town and lax Map number
b. Location of Installed oornponents tied to two fixed points
c_ System description C-9., 1 250 gal. Concrete saptic tank, etc.)
r
d. Installes' name and phone number
3. System repair to be performed In accordance with the above proposal and conditions
4. Tne proposal SS-1-0 repair Is aonsidarad a best fit design and there Is no guarantee to the duratlon at whioh the
complated GS-17S repair will function.
S. No complatad work Is to ba backfitlad until authorization to do so has been obtained trom the 17epartment.
Proposal Approved LI Proposal 17aniacl
a /�,
COPIES: PGFIO: Owner: Installer
PC -RP 99ML Rev - 2/07
Putnam County Department of Health
Division of Environmental health Services.
SSTS Repair — Final Site Inspection
Date: Inspected by: Installer: 1a� CfrZy�r�"
Street Location: f.. -St Owner:
Town: 111a, l' ' e Repair Permit #: TM #
1. Type of System: Conventional O Alternate ❑ Comments:
2. Septic Tank
Y s
No
N/A
Comments
a. Septic tank size 4 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 32'
iii. Pie slope checked ... ...............................
iv. Installed according to plan .....................
v. 10 ft. from property line — 20 ft — foundations ...
vi. Size of gravel 1/4 - 1 % " diameter clean .........
vii. Depth of gravel in trench 12" minimum .........
viii. Ends capped
_
'-Puin orlDosed S • stems
3. Sewa a System Area
a. SSTS Area located as per a oved 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 ............................
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Additional Comments:
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
_ . �IVISI N -OF EN.V.;RONIMENTA?_. HEALTH •SERVIGES'-
FIELD ACTIVITY REPORT
NAMA: Tel:
ADDRE 300- 4 s� hu UG �I� � - 3
Street Town State Zip
PERSON .R CHARGE
OR R TNTF VTFWFD: Zh c Pt i T�atP:
Na'p2 and itll
TYPE OF FACILITY: Psts i cko lI d
FINDINGS: C
d
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Signature and Title
RFpnRT RF-C FTVFTI RY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title.
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner: A-L, Address: e 3k
Located at (street): Tm# H
M lCipality:
on AM VrZ Watershed:
SOI1L PERCOLATION TEST DATA
Witnessed by: AV,
Date of Pre-soaking., Date of Percolation Test: 51i-Vidv-
V
Hole
No.
Bob
depth
(inches)
Ron
No.
Time.
start Stop
Elapse
Time
(Min•)
Depth to
Water from
ground
surface
(6ch")
Shift - stop
Water
level drop
in inches
Percolation
Rate
min/inch
i
10;0 ►0.3,*
2
30
3
3,Q
3 C)
4
2
3
4
5
2
3
5
2
3
4
5
Notes:
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., <_ I min for 1-30 min/inch, <2 min for 31-60 min/inch).
All data to be submitted for review.
2. Depth measurement's to be made from top of hole.
Form DD.97, pg 1 of 2
TEST FIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DE N :: <. _ 44OLE
G.L. * T S
0.5'
1.0'
2.0'
2.5' 54
3.0'. GE Lt/ P--erc-(jt I!j in .
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7:0'
7.5'
8.0'
8.5'
9.0'
9.5'
i
Indicate level at which groundwater is encountered 3
Indicate level at which mottling is observed AA
Indicate level to which water level rises after being encountered
Deep hole observations made by: u Date
Design Professional Name:
Address:
Signature:
Design ?rofessional's Seal �
Revised July 2013