HomeMy WebLinkAbout4230DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.81 -2 -12
BOX 32
titi 1,
. �. },,, i
.`
-, if ,'
UL
04230
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
YES
N-01
Internal Use Only
PERMIT - R4q -I L
❑
❑
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
19 Not in Watershed
❑ Delegated
❑
Repair within 200 ft. of a watercourse or DEC-mapped wetland
11 Joint Review
SITE LOCATION
OWNER'S NAME
]gS� _ TOWN Q��y��,y� Ur�el
TM #
PHONE #'
MAILING ADDRESS.
Lit
APPLICANT
vi'
Name & Relationship (i.e., owner, tenan ontiacto
DATE 1 Z -1 4 —`2— FACILITY TYPE �C, PCHD COMPLAINT #
PROPOSED INSTALLER IAt�tr[�j �� PHONE # fly- 9:94 3S�
ADDRESS (� C-�✓o "� for j[� r REGISTRATION /LICENSE # �� -5 6Z' y
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 the conditions star d on this form
SIGNATURE N' (� L�''f/ TITLE U/k _p�,- DATE �Z-
(owner)
I;-the septic instailer-, agree to-comply with the conditions of this permit for the- septiC system repair,„; _ -
SIGNATURE TITLE 11e� DATE l Z--1 �—h
pnstaller)
Proposal approved 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 backfilld until authorization to do so has been obtained from the Department.
7 INTERNAL USE ONLY
Pr pos I o Q� Proposa De ❑
n,`c1an (2 (2
Inspi or's Signature & Title Date Expiration Date
Repair DroDosal is in compliance with apDlicable codes Yes Ci;/ No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
AS BUILT DRAWING
�c ea 10oo cd. to V\
co
fo
p 6
j
r.
N
C
0
U
c
0
U)
06
c
m
J
m
N
N
M
m
�. �rIY�fOdYl
Dr
ee
DATE: J a.-, 1-0 ( -">
D
1 15-5 ( G
Zo 't0
u
1),-? I .-; ,
.wo
t ��
LEONARDI AND SON CONSTRUCIOM INC.
6 CAROLYN DR.
CORTLANDT MANOR, NY 10567
(914) 980.3554
Putnam 11c.# PC -560 West, Lic.# 067
�l i�fY
boa►^
AS BUILT DRAWING
cl?
<—r404
CP
(o
c7-
a
wjk-
O
N
GY4�ov\,
L 9 9- �cLA---p
r
LEONARDI AND SON CONSTRUCION INC.
.6 CAROLYN DR.
Ls�')
CORTLANDT MANOR, NY 10567
cr) (914) 980-3554
DATE: Putnam lic,# PC-560 West. Lic.# 067
. eoc; r
Putnam County Department of health
Division of Environmental health Services.
q SSTS Repair - Final Site Inspection
Date: ( \ 3 Inspected by: PA 0 L. Installer: o r`
Street Location: ( f =�`_ . Owner: _ t
5 /s � � �r
?5�� i�'_
Town:^ w u,h ,� Repair Permit #. -� -12 TM # i �^
1. , type of system: Conventional mKiternate u Comments:
2. Se tic Tank
Yes
No
N/A
Comments
a. Septic tank size ,000. . 1,250... other .....
✓�
b. Septic tank installed level ..................... •
c. 10' minimum from foundation ..................
✓
X��'�'t,�
1a7C� 90A
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 - ro erl set ............ • ..............
f. Trenches
i. Systemcompletely opened for inspection
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 3/< - 1 '/2 " diameter clean .........
vii. Depth of. gravel in trench 12" minimum .........
viii. Ends capped ..... • ....................:. • ......
g. Pump or Dosed Systems
3. Sewage System Area
a. SSTS Area located as per a roved plans
b. Fill section -
c. Distance from water course /wetlands
4. Overall Workmanshipa/
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:
R)FSI Rev - 011312
i a
0
0
-k 1�5-
j L U)d
pvbr4�
Aavx 6r-i6b6K
) q5- �r
Lam.