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04166
• RU ► NAM COUNTY HEALTH DEPARTMEN "i-
[)IVISION OF ENVIRONMENTAL HEALTH SERVICES C�
PROPOSAL PpR Si =WACzE TREATMENT SYSTcM REPAI
YES NO: " Internal Use Only PERMIT #
^tea ::u pair Frermii hKbido iti tasi's pdars•' Ci epair within Boyd's Corners. w. Brant» or Croton Fans Res. Delegated C3 pair witnin 200 d.. of a watercourse or DGC- mapped wetland ❑ Joint Review F �Q
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
IA ke 10CC.kS k16 OWNeu +W1� V41 tefM 4
G., h lta k a PHONE 41
DATE ?j _ y FACILITY TYPE PCHD COMPLAINT
PROPOSED INSTALLER CAP, f---v e IV1 Q f MS �� i Cru PHONE # f �/ — (oy'(� -`j 7d,Gl/
ADDRESS a� UC,n) 0 i4 �L S " AFL° REGISTRATION /LICENSE #
T
r000sa{ (include a eparate sketch lac n the house, pro erty lines, all adjacent welts 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
..union nnrl nv*nnt ni tha ronair
I, as owner,agree�to
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PA-0 P "
SIGNATURE TITLE �� t�>> `� t'; C DATE ?: "r n
(owner)
I, the septic installer, agree to comply 'th the conditions of this.petpmit for the septic system repair
SIGNAT -15RE TITLE 45" TR-010e4 -- DATF-
(installer)
.P- ro_7os+iatfir;,ved with he following coo Lions:
1. Procurement of any Town Penult, 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
a. System repair to be performed in accordance with the above proposal and conditions
A" 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 oackfilt until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal /approved
Proposal Denied ❑
�> c� � S o
Inspector's Signature & Title'-Z-,7. //
¢ �5>/z -3/z 6� Repair Proposal proposal is in compliance with apolicabls codes YES
COPIES: PCHD; Owner; Installer
PC -RP 99ML
on Date
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DiviSiON 0F.ENVIROMMENTAL HEATLIUSERVICES
FIELD ACTIVITY REPORT
ADDRESS:
Street Town State F Zip
45"
PERSON IN CZAIRG—E
Nam and Title
TYPE CELITY
rFF A,
WINGS-.
Hr.
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et,
4,
3.O 1 -4— 3, o'
1 47"d, * f'. /"e.
4f
Z411 7
7-le vwj-,
W q., �5 (
W0,PECTOR, TF.T
Signature and Title
R'F.PQRT IRF.C.F.TVP-T) BY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
YES
❑
a
SITE LOCATION
OWNERS NF
MAILING ADC
APPLICANT
PU i NAM COON i`Y HEALTH DEPARTMENT
PIViSION OF ENVIRONMENTAL HEALTH SERVICES
ROPOSAL FOR SEWAGE TREATMENT_SYSTEM REP)
Internal
PERMIT #
Q
s
N _
p i:.�t'�yEl3r�- =��- - T: -•.. - �t_:1�7-Vi�c:ti?rs�lE'fi -•-
Repair within Boyd's Corners, W. Branch or Croton Fails Res. WDelegated
Repair within 200 P. of a watercourse or OG-C- mapped weu C1 g
and Joint. Review b
LA kG 'Pe r- ks ki /hOW N PEA i WA-4 V-4 ix
DATE 3 I _ 1 O FACILITY TYPE PCHO COMPLAINT #
PROPOSED INSTALLER `/ Q t4 f M r S H004-
=- -�.ItT c ONES
PH
ADDRESS a(P tea. D� r'�- 1. &, )C REGISTRATION /LICENSE # __
Proposal (include a eparate sketch loc tin) the 11/66se,7porlperty litres, 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 ago extens of the repair. .
_tp
i, as awn ,agree to the cond'�ions stated on m form
is *-�A C, 1, c J- PR
rl-I� P•
SIGNATURE li:�
-4A ( t'�..� iC�:r� TITLE DATE
(owner)
I, the septic installer, agree to comply it the conditions of this.periWK for the septic systern repair
SIGNAT -JRE TITLE 4J jJ ` p 4PeeR— DATE—?-;: 7'/()
(installer)
�. ProLasyl MP need Witte trig fi,llowina• conditions
: ,
I . Procurement of any Town Permit, it 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. Syst.cm 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
a. 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 oacicfili until authorization to do so has been obtained from the Department
1NTERiVAi_ USE ONLY
Proposal Approved Proposal Denied ❑
3 S d
inspector's Signature & Tide DEO I Expiration Date
Reoair or000sal is in compliance with apot.icable codes YES El _ No 0
COPIES: PCHD; Owner; installer
PC -RP 99ML Rev. 2/07
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SUPERIOR. PRODUCTS.
ENVIRONMENTALLY-FRIENDLY PROS E"
DI It E C
,
' 'M'ATBRIALIS, AND J".' GVATJO 'N -9
y
01JR EN VIR ONMENT IS 0 (R. B-USINESS.,
MODEL
MODEL'
DESIGN CA
TOTAL
C"ACrr Y
H
LENG TH
WEIGHT
(MMIfiUnk)
(P
YUS
CAPACITY
n)
-Poi6ds
Gallons
! �
40 7 4" U
2 Wid 1.wie
Rfvff-300
ST-300
300 (1136)
325 (1230)
273 (1033)1294 (1075)
54 (1372)
45 (1143)
50 (1270)
120(54.43)
(single lay-)
WW466
ST7500
50'0 o893
535:(2025)
452 (1710 )/474(1794)
51(1295
62 (1575).
601 (1524),-
225 (102.06),
RMT-750
ST-750
750 (2840)
1000 (3785)
853 (3229)/898 (3399)
51 (1295)
62 (1575)
103 (2616)
360 (163.29)
RMT-900-.T
ST 9Q0
90 Q107 -7-
1161 (4394)
990.67471!1028-(4891)
51.(1295)-
-
62
1j8(2997).
0 (29.4.) 2)
�(3785)
14610 394), .,
374.7y 1028f(3891
5 k I
(204,•2)&'-
RKr-1060,
ST -1060,
1060 (40 lij.
1337 �5061)
117.7 4455 1227 (4645)
51,(1295)
133(3378),
520,(235.97)
RAT -1250
ST-1250
1250 (4730)
1469(5560)
1259 (4766)/1319 (4992)
51(1295)
62 (1575)
148(3759)
560 (254.01)
ST -1. 1.
1500 (50
1771 (67R3)
J—
:1540 (5830)(1601(6060)
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Size (WxLxH) ....................:...22" x 53" x 12" (56 cm x 135 cm x 31 cm) ,
Storage Capacity ...................... 32 gal (121 L)
Louvered Sidewall Height ......... 10" (25 cm)