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Home My WebLink About4207DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.80 -1 -71 BOX 32 04207 ., j 166 111 1:1 6 Ij IRI or I K i' r I � , r � r', M 04207 . ,. •'.a,; ..-- ... :�., -gib .,; ==:� - r ._ . / PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES DPOSAL-FOR SEWAGE-TAEATMEN"YSTEWREPAI - . Internal Use Only PERMIT #I' U 6Z Repair Permit issued in last 5 years bA Not in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ y Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION '�f'c�ltr�t' �'_ WA TOWN OWNER'S NAME MAILING ADDRESS APPLICANT Name & Relationship (i.e., owner, NE #q73- - $Q7i1 DATE t0 r.` a1 -� _ FACILITY TYPE' ;r ,p Qa,,,',1 A PCHD COMPLAINT # PROPOSED INSTALLER 1'�r^_; ,;�-�r , ��}�,, ' PHONE # ADDRESS REGISTRATION /LICENSE # 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) •`y�.J NOTE: The Department may require submittal of proposal from licensed professional depending on the �� °'� nature and extent of the repair. I, as owner,agree to the conditions stated on this form SIGNATURE '�� TITLE 7CC— DATE (owner) 1, the septic instalWagree mply t onditions °of this permit for the septic "system repair C SIGNATURE TITLE DATE (Installer) Pro2osal aooro ed with the following 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 backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY . PProposal Approved 4, is in comalian& with Proposal Denied codes El //A///'-/ D to Yes Date P� No ❑ COPIES: PCHD; Owner; Installer ' PC -RP 99ML Rev. 2/07 Aj09 Oros \,Om, 6a�lvn p�c�c..lr.'Tan1S .a Homeowner: David and Robbin Motyl 36 Traverse Road Lake Peekskill, NY; Town of Putnam Valley Tax Map: 83.80 -1 -71: 9 Installer: Philip Leonforte (License #1022) Precision Excavating Inc. 3 Rochambeau Road' Garrison, NY 105241" , (845) 736 -0571` i, Description of Repair to System: Installation of 80' of Infiltrators With 11/2" Washed•Stone Installation Complete: 11 -6 -14 Scale: 1"= 20' Legend: A -1 =46' B- 1p -.Ill A -2 =36' B -7-1 6' A -3 =7' B- 3 * =44' Putnam County Department of Health Division of Environmental Health. Services SSTS Repair — Final Site Inspection Date: / k �� Inspected by: Installer:��c�_Sit,�j�C Street Lo ati n: 3 a Owner: U4.4 1. Type of System: Conventional 0 Alternate 0 Comments: 2. Se tic Tank Yes No -N /A Comments a. Septic tank size —1,000 ... 1,250... other .... . b. Septic tank installed level ...................... c. 10'm inimum 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 n Ail ii. Length required Length installed iii. Pipe slope checked iv. Installed according to plan ....... :............. v. 10 ft. from property line — 20 ft .— foundations ... vi. Size of gravel' /. - 1 '/2 " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... ... End`s c & : . �. . ................................ g. Pump or Dosed Systems 3. Seware System Area a. SSTS Area located as per approved 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 ............................ Additional Comments: RFSI Rev - 011312 1 Y ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health MARYELLEN ODELL County Executive • - -� rs� � � +...Z. :'.� :^.•nab _ -... �,,tc: ��i F >•r �y.�.. \r -.. .v t =�. a. - -� DEPARTMENT OF HEALTH 1 Geneva Road, Brewster,.New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 C. YEN*#; –,,"94 Address: sc toy t, -0. Y► Date: Iiu1`� Repair Permit #: `12 _ J-x- /'l -/Y IL -rowtq Pik ®PE�y i3ECY-EP-- 3 cn .Ii.IJCE.. F�6P -...iu c :•e,v .. -. - e+.^',.. �:.�?i'.a:;:. . Public Health Director Y 1 Geneva Road - -Brewster, New York 10509 Associate Public Health Director Director of Patient Services ATTENTION: a JOSEPH PARAVATI a GENF, REED All information below must be completed prior to any scheduling. ADAM FNGtl�ER OR FIRM. n� �n _� ��c3� i s� c.1 PHONE #: `i�— Z� -05 '1'� 1, , DEEPS: ?< P EROS: a PITW TEST: ❑ ROAD /S'T'REET: TOVM: A- 'T'AX b1AP►#: 1b�5 SUBDIMION: LOT #: IYYCDEP CTt1TERIA FOR J ®lam REVIEW AlmPtESSI(iG OF SOIL TG NO ❑ Proposed SSTS within the drzinage basin of WestBranch orBoyds Corner Reservoirs. _..ft sed. SST8..witMn 500 f ofA. rt- ssrvoir,- nnrvoir•steem or colmtrot lam: _ - ❑ Proposed SSTS wiith& M feet of a watercourse or a DEC wetland. ❑ Proposed SSTS design Bow greater than 1000 gallons/day or SPDES .Permit required. o Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCIDEP project status (Joint or (Delegated) based on the response. If you mmwered M to any of tke questions, NYCDEP must witness the soil tests. This (Department will coordinate a mutually suitable time for Field testing with the Design Professional and NYCDEP. If a project has been determined to be Delegated based. on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: IMM. bpmm 1m (FIBLDTEST) DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM owner: LWAtod at (street): .J /J Cf yerL' Manicip Mr. �ii�/>6104) V ti Address' TM� watershed: SOIL PERCOLATION TEST DATA witnewed by: Date of Pre-soaking: 3 ( Date of Percolation I 1 I I ♦ 1' I I I I II II I II 1 I I V I 1 1 1 1 II li Notes: 1. Tests to be repeated at some depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., :5 1 min 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 hole. From DD-97, pg 1 of 2 TEST PIT DATA DESCRIPTION OF. SOILS ENCOUNTERED IN TEST MOLES DEPTH - HOLE # ! HOLE # HOLE # HOLE # HO ... ... • G.L. 0.5' 2.0' 2.5' 3.0' 3.6 4.0' 4.5' 5.0' 6.0' 6.5' TO' 75', 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered AP�7 Indicate level at which mottling is observed / `' Indicate level to which water level rises being encountered /V h Deep hole observations made by: Date l f Design Professional Name: 0-4 Signature: 7 Design Professional's Seal � I Revised July 2013