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HomeMy WebLinkAbout4214DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.81 -1 -33 BOX 32 04214 .. , y -IN Is 0 8 :;; n L I Y. I No Is so ,N , , 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 132 4 P 24 -- 23 22 21 Edge Of Pavement Town Of Putnam Valley Tax Map #83.81 -1.33 Area= SUMN11100FARINCR 12 pWj3 ?r;7 47 6 16 19 46 7 15, 20 14 Im ol 44 22 �2 41 90 39 25 Olp 26 67 4 66 4 ,33 \50 132 511 \\54 d 32 57 1 /58 59, so —34 112 Ift 0 9 .25-1 29 198 TM L,. --- I'LLM um --- MM LIMIT ZAAF an uo morGU L 1 i 1 6 M. a i- ;�-_ 1 123 1 i25;li 139 1 at x40 morGU L M. a i- ;�-_ CUSTOMEh'S ORDER NO. PHONE DATE NAME ADDRESS k; g'i MT-Dj A. I OK LLC; SOLD B::" CASH C.O.D. CHARGE ON ACCT. MDSE. RET D. PAID OUT SOLD BY 1) Rc . I I . `ail N11061TRME., "fiC)IRK 54��,>; 'R NINE I Py R M CUSTOMEh'S ORDER NO. PHONE DATE NAME ADDRESS k; g'i SOLD B::" CASH C.O.D. CHARGE ON ACCT. MDSE. RET D. PAID OUT SOLD BY CASH. C.O.D. CHARGE ON ACCT. MDSE. RErD. PAID OUT A -i 5 'R NINE I Py R M _M� -- — ------- .1 A T . ......... ... ....... TAX- -- RECEIVED BY TAX TOTAL RECEIVED BY• t: TOTAL PROI)k�CT 610 All claims and returned goods MUSt be accompanied by this bill. lY Ip 6 E6, 42! F CUSTOMER'S ORDER NO. PHONE DATE IM, A, NAME Ar k; g'i gi SOLD BY CASH. C.O.D. CHARGE ON ACCT. MDSE. RErD. PAID OUT A -i 5 F CUSTOMER'S ORDER NO. PHONE DATE NAME ADD RESS SOLD BY CASH. C.O.D. CHARGE ON ACCT. MDSE. RErD. PAID OUT -- — ------- 7 . ......... ... ....... TAX- -- RECEIVED BY TOTAL 1— VUUUb MUM ut: duuumpanieu oy ims bill. cc J