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83.75 -1 -19
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04174
PUTNAM COUNTY HEALTH DEPARTMENT O
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use
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PERMIT # � 1 �LI
Li Repair Permit issued in last 5 years K 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
TOWN WV'J,—
Vv' TM # ;d y
PHONE # ibrsi -�
:lad
APPLICANT ' J 0 M GUM- r! c? C 64 I l ,J`l
ame & Relationship (.e., owner, tenant, connt ctor) / �!
DATE Cl �C O FACILITY TYPE ' ! y�`� rt9l`PCHD COMPLAINT #
PROPOSED INSTALLER �C
I c/�C4 L 61 PHONE # ? qC 6 61 013
ADDRESS 3 �w�L Vri 1, EGISTRATION /LICENSE # PO 037 -0 OIZ023
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 th p repair. �t
(Z" 16YLsO- °1- T
I, as owner,agree to the conditions stated on this form n
SIGNATUR�� �' TITLE �i �f DATE 7 1-e. l a
_(owner)
I, the se u installer; agl'e omply wit the corditions of this permit for the septic system " repai /r
SIGN A - TITLE l�r DATE
(installer)
Proposal approved with the following conditions: 1
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.
Proposal Approved
re & Title
INTERNAL USE ONLY
Proposal Denied
is in compliance with applicable codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
� to
Date(
Yes
!°A 5 /o
Expiration Date
No ❑
Rev. 2/07
Sherlita Amler, MD, MS, FAAP
Commissioner of Health
�,�: s. . � .�-• Rdhcr�I°+�or- ris;�RE-- - ..,� -,�:,, ..
Director of Environmental Health
October 19, 2010
Matthew Faranda
333 Westchester Ave.
White Plains, NY 10604
Dear Mr. Faranda:
Robert J. Bondi
County Executive
Department ®f .Health
1 Geneva Road, Brewster, NY 10509
Office (845) 808 -1390
Fax (845) 808 -1937
Re: Field Inspection at 9 Oriole Street
(T) Putnam Valley, TM # 83.75 -1 -19
An inspection of the septic system repair, at the above referenced property was completed on
October 7, 2010. The system was installed as per permit number R- 243 -10, and found to be in
compliance with applicable codes.
If you have any further questions, please contact me at..(845) 808 71390, ext. 43261.
.V;... .�...- �...•_q♦wno..- .a�a.6a- mow•- -..... ..... _.Te -C "R• c"�. ...+y J,..... ..., .c -u r+".... .S+t-- ♦9..- ._...�•A..rs�.. -..,� v + -_v o� ........ ++L -Cf �Pc G
Sincerely,
0'r
Gene D. Reed
Sr. Environmental Health Engineering Aide
GDR:kly
10/19/2010 11:20 FAX
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Sheet of
PUTNAM COUNTY DEPARTMENT- OF- HEALTH
FIELD ACTIVITY REPORT
AT)MRSS: BZWA MAO&
Street Town State Zip
PERSON IN CHARGE
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Name and Title
TYPE OF FACILITY : S S
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e and Title
'RF.PQRT'RFCETV'ED'BV:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
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- PUTNAWCOUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE
All Information below must be fully completed prior to any scheduling
Pa 79�4,0L m Ai/fv _
SITE LOCATION TOWN 61 -f �V TM #
OWNER'S NAME PHONE #
MAILING ADDRESS
PROPOSED CONTRACTOR /INSTALLER La61 16 1-) PHONE # f -k�S6�p
ADDRESS 3 REGISTRATION /LICENSE # 'PL. 3'0
e son for exploration: ,
iiure to surface O back -up, In house 0 find limits of system for repair 0 other (explain below)
& Title
r o le
Date .�
Date: A Time:
kiy:excetseptic
41
140r1: I — - - - --
38
371
DRIVE
---
III
16
2
A/
12
— -- — — — — — -- — —
— — — — — — — —
135 M
— - - - -- — -
211
1
9
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4
- - - - -Y
114.09
jor
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- -• - --- -
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- - - - -
14
DIWWO AREAS
CWIMS CWWRSM
Ralo R.O.W.
STWEA"AYMME
SPECIAL DISTRICT L.
SCHOOL olsma I
'w I ol
— —
17
— — — — — — —
57
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17
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20
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12064
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112.22
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— — — — — — — — jot 907 — — — — — — — —
115.54
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16
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135 M
— - - - -- — -
15 N
9
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- - - - -Y
114.09
jor
N
-.4
- -• - --- -
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- - - - -
14
DIWWO AREAS
CWIMS CWWRSM
Ralo R.O.W.
STWEA"AYMME
SPECIAL DISTRICT L.
SCHOOL olsma I
— — — — — — — -
— —
17
— — — — — — —
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AP
17
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7;'
• - - - - - - - - - - - -
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12064
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112.22
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9
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— — — — — — — — jot 907 — — — — — — — —
115.54
Ito
140
— DISI'MO AREAS
— COKTIKMS OWW"tp
— ROAD FMI.
I— STREAWWAIMM
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3
STATE LINE
CDUNT I LINE,
TOWN LINE
WILuw- Litt
PROPERTY LINE
DIWWO AREAS
CWIMS CWWRSM
Ralo R.O.W.
STWEA"AYMME
SPECIAL DISTRICT L.
SCHOOL olsma I
140
— DISI'MO AREAS
— COKTIKMS OWW"tp
— ROAD FMI.
I— STREAWWAIMM
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PGTN, --yI COUNTY DEPARTMENT OF HEALTH
DI ISION OF ENI VIRON�tENT_ -kL HEALTH SERVICES
DES ION- DATA SHEET = SUBSURFACE SEWAGE TREATTLVLE_iT SYSTEM
Owner: GL%»h, i Address: gT
Located at (street): TM T Section: _ Block- _ Lot
Municipality: fisT��11,441—E-4 Watershed:
Date of Pre- soalcin;:
SOIL PERCOLATION TEST DATA
Witnessed by: _
Date of Percolation Test:
Hole tio.
Run No.
Time
Start—
Stop
j
I
Elapse
Time
(min.)
Depth to
water from
. ground
surface
Start - stop
`Water
level drop
in inches
Percolation
Rate
miniinch
! 1
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2
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4
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Notes:
r, . p
2.0'
2. 5'
TEST -PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
i-.GLE HOLE- # HOLE -HOLE-4" 5Z- -.'(, D, L E
1191."ll e- CIA
I
3. " 41150"'A
4 i.3'
4. 5'
0
7.0' 'A 'A
9.5
10.01
Y" o - ro,
Lridicate leve! at wHich grourndwate,- is encountered
Lndicate level at which mottling is observed AloQC_
Lrid-ica.7e Leve [ to wEch water level rises afzL-- e _ z e-11coun. tered
Dee^ ho[e.obsenrations made by: Date
Desia-n Pro sessional Nave:
Address:
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16