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HomeMy WebLinkAbout4290DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.83 -1 -30 BOX 32 1 rm I I pi J r. 16 IL A I �. 1 . . -� ` 04290 - PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES YEa NO, Internal Use Only PERMIT- i -V ❑ Repair Permit issued in last 5 years 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 (,'��,Vy TOWN ,y TM #�3'(�3�4��C OWNER'S NAME PHONE # / X2 Z21?1 L MAILING ADDRESS APPLICANT C- Name & Relationship (i.e., owner, tenan con ra or DATE tlgya a 5. ao / I FACILITY TYPE `j b 5 PCHD COMPLAINT # PROPOSED INSTALLER A%RGW (!yccau, T,-.r -. _! " C PHONE # 8Y- 5W2,0-40Zt�" ADDRESS REGISTRATION /LICENSE # Z. 16 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 I, as owner,agree to the conditions stated on this form SIGNATURE ��pmberei�iG� ®��• TITLE- f�J%mcu;ojcP DATE tA*v-tL Za Z&t,c (owner) - - . -; talleryagrea4o-bomply-wina the conditions- of this permltforTiiatw SIGNATURE l"% TITLE �Qzsti�,� DATE ry�rt`„?�� 2,_ (installer) 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 backfil!pd until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pr osal Approved Z Proposal Denied ❑ In pector's Si ature & Title Date Expiration Date Re air proposal is in com liance with applicable codes Yes 0 No Q q q P pP COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ar JOB g,L,d ARROW EXCAVATING, INC. SHEET NO. 12 OF_ 15 AVALON COURT HOPEWELL JCT., NY 12533 CALCULATED DATE7__r.? .(845) 227-4505 (914),528-4395 SCALE /emu 7 ................ .. ... ......... ............. 4 ........... . ............ .......... .. .............. ............. . ............. ............. ............. ............. ........... .. ............ .............. ............. . ............. .............. .............. ............. .............. ............. ............. .............. ............. ............. ............. .............. ............. ............ .............. 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I ............................ ........ .. ............ . .. . ....................... . ........... .... ...... .......... ............. ............... .............. ............. . ............... ............ ........... ............. ..... ........ .............. ..... ..................... ................ ............. ............. ... . .............. ............. ............. ............. .............. ..... ....... ............. ............. ............... ...... .. a 1. ............. ............ ........... ................. ............. i .............. ... .......... ............. ..... ............. .............. .............. ............. .......... .... .............. ............. .......... ............. ....... ..... ............. .............. ...... ...... ........... ..... . ..... ............. . ........... . .. . . . . . ..... . . ..... .......... .............. .......... A/ ?-2:�E I . ....... . �4.4.".' . ... . ......... ............. .......... ....... ............ 4 . .......... . ....... ..... ....... ........ ............. .............. ... ............. ............. ........ . .. ... ....... ............. ............. ............. ....... . ................ ......... ...... ............ ............ . ............ ............ .............. ............. ............. .............. PRODUCT 204-1 (Sin& Sheets) 2*1 (PaMed) JOB A D , ARROW EXCAVATING, INC. SHEET NO. �� G�o�,vf Pit OF V+Q-; & L/el'«`may 15 AVALON COURT _ HOPEWELL JCT., .NY- 12533 -• CALclJ AT_ED BY �'� CT�" -�— DATE ,ate � 1 t -�t� .'r � s; •i: ii. r. c -i�Fi t. vv s.. • -• - .H'•e:•.= .,�s".'�:�p„�:': ,' -. �•,g �..A�•,K.,a�..:..dn <... •vn`~ �. CHECKED BY DATE e PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information must bed completed prior to any scheduling. Date: Engineer or Firm:. Person to Contact ❑ New Construction PRepair Program ❑ Reason: Deeps Arcs ❑ Pump Test Phone #: �c�> '�Z 1 as Addition Program Road /Street: _ ,�%l.�•�T %� Town: " Tax Map #:�j Subdivision:. Lot #: Owner: _T/z,Z/00 ❑ Project not within NYC Watershed. NYCDEP CRITERIA POR .iOIN- PREVIEW AND WITNESS C OF 50LI< E.� YES NO ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner ❑ .� reservoirs. Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ V 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 NYCDEP project status (Joint or Delegated) based on the response. If you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professions 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: f f ! O TIME: ate _goo COM NtENTS: �i Req.for field testAl'y 4/16/2009 . , . fell it Val loyn art a zo 41 41val so It fit In IBM woo Sheet of PUTNAM COUNTY DEPARTMENT OF.HEALTII- , , .._ � __._......... FIELD ACTIVITY REPORT AnnRFSS: 12 a- 10dwl' 7�'L, it l Street Town State Zip PERSON IN CHARGE Z�`f Name and Title ` TYPE OF FACILITY: FINDINGS: 0 0 T/ /mg. wt TNSPECTM, TFT Signature and Title RFPnRT RFC'FTVFn RV: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: r fa v� T/ /mg. wt TNSPECTM, TFT Signature and Title RFPnRT RFC'FTVFn RV: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: