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83.81 -1 -33
BOX 32
04214
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04214
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.!, ,
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES NO Internal Use Only PERMIT # -
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ AT Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland j❑ Joit t Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
TOWN Lt ?' F't =Ft z ,1 I VXTM #
APPLICANT _ Q(X)n &P-
Name & Relationship (i.e., owner, tenant, contractor)
PHONE# 194S-a9q-,�tOLP
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER 12� C--, k � PHONE # R45 aAy- �Q
ADDRESS q 5 426 _ -i;� I I) NCI 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)
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 th conditions s ed on this form
SIGNATURE TITLE (TjL,vr1E{Z_ DATE
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE TITLE DATE
(Installer)
Proposal approved with the following condftions:
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
Proposal Approved ❑ Proposal Denied ❑
Inspector's Signature & Title Date Expiration Date
,Repair proposal is in compliance with applicable codes Yes O No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
as m
?IJ71NAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONTfENTAL HEALTH SERVICES
DESICrN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Ow
ner: Q
Located at (street ): L &00
[municipality: Loke- KA-skl ` G,( M.
Date of Pre - soaking:
Address-, '� s Lew-e' l R&
$3.2k 3
3
T Section: i Block ` Lot
M �
V411 Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by: _
Date of Percolation Test:
Hale No.
Run No.
Time
Start —
Stop
Elapse
Time
(min.)
Depth to
water from
ground
surface .
(inches)
Start - Stop
Water
level drop
in inches
Percolation
Rate
rain /inch
i
z
3
4
5
I
{
2
{
3
{
4
.I
I
2
3
2
3
4
5
{
{
Motes:
t. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hale. (i.e... < t mite for 1-30 min/inch, < 2 min for 3 1-60 min/inch).
,ill data to be submitted for review.
2. Depth measurements to be made Prom top of hole.
Form DO -97, pe I of
TEST PIT DATA ,
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE # HOLE # HOLE # HOLE # HOLE #_
G. L. S
0.5'
1.0' L& AL
1.5' o Lk
2.0'
3.0'
3.5' �o vk
4.0'
4.5'
6.0'
7.0' -
7.5'
8.0'
8.5' -
9.0'
10.0'
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed A}
Indicate level to which water level rises after being encountered
Deep hole observations made by: Date 116
Design Professional Name:
Address: � I
Signature:
Design Professional = Seal
,aline
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CUSTOMEh'S ORDER NO.
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PROI)k�CT 610 All claims and returned goods MUSt be accompanied by this bill.
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