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HomeMy WebLinkAbout4295DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.83 -1 -42 BOX 32 IL L' �-A le me 1.6 ' 1 f 9L 1 �r Ll 1r 04295 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES __.PROPOSAL- FOR-SE:1Ma GE TRE/�� 3' SYSTEM- REPA►11 -2:.. YES NO Internal Use Only PERMIT El Repair Permit issued in last 5 years Not in Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ LIa Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION A i `t't' T� TOW N��� IWiFtk� A ce y TM # 3 i$ 3 / Y', OWNER'S NAME TRTP.i C t *I I��Q� M F-s f- ilii ICCA n.0 V PHONE # 14S' 'T29-VIZ/ MAILING ADDRESS e sy' •t`-r 5 r F L K E T r ePf'kd 1 1\1 Y i APPLICANT i" f,cJ Rp G XR4 Cr-'T Name & Relationshi r e owner tenant contractor) a wil DATE % v70 /S F�°`CILITY TYPE a G PCHD COM ©PLAINT # PROPOSED INSTALLER jrtiA R9 G iR 14 (o£RT PHONE # ADDRESS o S C- REGISTRATION /LICENSE # S° J 9 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. k- 0 6 6 R o re c (t. .7 4F- %2 LV f 4 i-[ F, 16 I, as owner,agree to the conditions stated on this form SIGNATURE ITLE W ,\j DATE Z 113 ZC /S (owner) • ••. • I thy- s ®ptic ms.a #e ; agre- to comply with -the conditions of this permit far the septic system repair SIGNATU TITLE DATE (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 backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Propos I Approved Proposal Denied ❑ I e s Signature & Title t . 11p ration Date Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ETC ILJ too 41. � 5� 5� Sao s .. ... ........... ..... .. .... .. L IT . . ................ -3— Act+ 4s%c Putnam County Department of Health Division of Environmental Health Services SSTS Repair — F6d Site Inspection / 1� Inspected by: Installer. l; _ {�:: _ - Town: , Repair Permit M TM # ��I�.Typc of System: Conventional ❑ Alternate 11 Coarrnenb: 2. c Tank Yes No N/A Comments & Septic tanks' —1, ...1,250... other ..... b. Septic tank installed level ...................... . c. 10' minimum from foundation .................. d Didrikgdm Box L All outlets at same elevation (water tested) .. . ii. Protected below frost. ....... ... ............. iii. Mmimum 2 & Original soil between box & truclIes e. nn — ro set .......:................:.. E. � ' L System completely opened for inspection u. Length required Length installed , iii. Pipe sWe checked ... ............................... iv. Installed according to plan ..................... -7 v. 10 ft. from property line — 20 ft — foundations ... vi. Size of.-gravel % - l % " diameter clean ......... _ vu. DqA- gfgravel: _ cl 12mn MM . vYL 1 9. or s 3. a. SSTS Ana Wted as per approved plans / b. FM section — ! c. Distance fivm water coursetwedands 4. Overall WirknmuidP a. Boxes properly grouted and installed correctly ........... Lz b. All pipes flush with inside of box ......................... c. BackSll 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 ............................ ►dditional Comments: RFS1 Rev- 011312 PUTNAM COUNTY HEALTH DEPARTMENT -- DI`JISION .OF FNVIitCT�AI= .F�LTH...SE'En7I� :.: PROPOSAL FOR SEPUM DISPOSAL SYSTEM REPAIR OWNER'S NAME SITE LOMTIOV ;; Lei &I s) F 5 s DATE V` �11G;' Y1, I z L" *10 PCHD Canplaint # Name & Relationship (i.e, owner,tenant, etc.) 1 TYPE FACILITY 5 e� PHONE REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different - location may require submittal of proposal fran licensed professional engineer or registered architect. rA S (1J x 15 11 n c D n ,P . .L/",// 7 i'1 r' /2-- -7ZJ09 _ - 1�� z. � e'lf ati.0 t c.eers-� 00;/ Proposal approved Proposal Disapproved Inspector's Signature & Title Da Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE T a TITLE DATE A& [PIES: V&te (Mb); YeUcw 03m BI); Pink Lk#icent) (EALTH DEPARTMENT UWAL HEALTH SERVICES DISPOSAL SYSTEM REPAIR 0 15; PHONE TK# PCM Complaint # owner.tenant, etc..-) TYPE FACILITY PHCNE wells). k-ae type as original sewagp"disposal. system. )posal from licensed professional engineer or Proposal approved Inspector's Signature & Title 't Disapproved IJ Proposal approved.with the followihg conditions: 1. Procurement of any Town . ,if applicable. P�MI&t 2. Suhmission of as buil-,repair sketch in duplicate showing: a. owner I s name. b. Site Street Name, Town and Tax Map number. c.* Location of installed canp-d`�ntw' tied to two fixed Points d.—System description 80 gal. concrete septic tank,, dry�,'ls surrounded bi-o'ne foot + gravel). e. Ifistaller's name and number. (e.g.,house corners). three precast 61 diam. x 61 deep 3. System repair to be performed in accordance with the above proposal and conditions. as owner, or reported agent of owner agree to the above conditions. SIGNSIGNATURE TITLE DATE 1:: Mite (PCHD); YeUcw (T= ED; Pirk. (k lint) 2. (EALTH DEPARTMENT UWAL HEALTH SERVICES DISPOSAL SYSTEM REPAIR 0 15; PHONE TK# PCM Complaint # owner.tenant, etc..-) TYPE FACILITY PHCNE wells). k-ae type as original sewagp"disposal. system. )posal from licensed professional engineer or Proposal approved Inspector's Signature & Title 't Disapproved IJ Proposal approved.with the followihg conditions: 1. Procurement of any Town . ,if applicable. P�MI&t 2. Suhmission of as buil-,repair sketch in duplicate showing: a. owner I s name. b. Site Street Name, Town and Tax Map number. c.* Location of installed canp-d`�ntw' tied to two fixed Points d.—System description 80 gal. concrete septic tank,, dry�,'ls surrounded bi-o'ne foot + gravel). e. Ifistaller's name and number. (e.g.,house corners). three precast 61 diam. x 61 deep 3. System repair to be performed in accordance with the above proposal and conditions. as owner, or reported agent of owner agree to the above conditions. SIGNSIGNATURE TITLE DATE 1:: Mite (PCHD); YeUcw (T= ED; Pirk. (k lint) J1VPUTNAM COUNTY HEALTH ?ARIMUR D1�4$10WQF., TIRONMENT W ­ ALIMUM SERVICES N MOiGE DISPOSAL SYSTEM REPAIR OWNER'S NAME PHONE SITE LOCATION MAILING ADDRESS PERSON INTERrEWED PCWC4omplaint#­-- Name & Relationship (i.e, owner,tenant, etc.) DATE ,,TYPE FACILITY PROPOSED" INSTALLER PHONE REGISTRATION Proposal (include sketch locating all adjacent wells): NM: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. -ems Proposal approved -Disapproved Inspector's Signature & Title romsal amroved with the followinq conditions: 1. Procurement of any Town permit,- if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed campon�n6s tied to two fixed points d.—System description (ewg,-;-- 1250 gal. concrete septic tank,,.. drvwells surrounded bY­ofie foot + gravel). (e.g.,,house corners). three precast 61 ciiam. x, 61 deep e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditi6ns." as owner, or reported agent of owner agree to the above conditions. . 1/7 SIGNATURE TITLE DATE OPM: Vibe (PCH)); Yellcw (Tmn ED; Pink (Appliamt) PUTNAM COUNTY DEPARTMENT OF HEALTH mp l a i n r--Oe 3 6 7- 9 8-1 9 ' o COMPLAINT OR SERVICE REQUEST RECO D • .._... .r5! : , .... t . s r! x.r .. v. +:vp .J ... ,—'t h._ �♦~y lei TOWN P u t n am V a 11 e y DATE 05/28/98 REFERRED TO TAKEN BY PM TELEPHONE.CALL _I_ IN PERSON LETTER CONFIDENTIAL REQUEST FROM Andy Trainor TELEPHONE- 528 -9335 ADDRESS 48 Hewitt Street, Lake--Peekskill ENVIRONMENTAL HEALTH: Sewage Nuisance _X Public Health Nuisance Chemical Emergency Individual Water Other COMPLAINT OR REQUEST At 54 'Hewitt Street - buryine, oil tank and old HW heater using for septic - no permits. ACTION TAKEN BY M L C D L u DATE 61f If Y FINDINGS 1P / G .5-A � N -1 a..J I- 1 / r. S4,j l 4"C- DATE FINDINGS DATE FINDINGS PROBLEM ABATED DATE $ PERSON NOTIFIED✓r V-- ESTIMATED TOTAL MAN HOURS SPENT r PC -CR L81W 02/18/1994 22:39 SI9 914 - 734 -7320 ALL PRO ROOTER :mow - 20 PAGE 02 !'A LM AMRWS 5AM£ AS 5iT�, L,oCgYi , PUISaM UMMU W ?A C- cA" o PLC 'Complaint # kjo,) L .. Name 6 Relationship (i.e, anw,trwent, etc) ICti�, RATE ` TYPE izii ITY hyposal _(include sketch locating all adjacent wells) . !10►1'E: Repair must be in same lotion and of same type as original sewmp dlapoeal system. Xifferent location may require submittal of proposal fran licensed professional engiraw or 1►dV � 6iA..di �..n�. � t•dwf• r , S with the follawina conditions: 1. Procurement of any Tom permit, if appTicsble. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed aopponents tied to two fixed points d. Systen description (e.g., 1250 gal. concrete septic tank, drywells surrounded by, one foot + gravel.). e. Installer's name and number. (e.g.,hom oorners). three gremst 6' diem. x 6' deep 3. System repair to be perfozmed in accordance with the above proposal and auditions. 02/18/1994 22:39 914 - 734 -7320 ALL PRO ROOTER PAGE 03 o .. Elmor ®a lowe Bto s9 ~- Katonsh,Now Yo vlt 905 914.232 -8888 914- 737 -8886 RICCARDO 54 HEWiTT STREET' LAKE PEEKSrJLL. 14Y 19537 °VOTE SEPTIC REPAIR PROPOSAL Ff.T.SCALEI LOCATIONS OF EOSTING GREY WATER SYSTEMS ARE APPROXAMIT[E. HEW ITT STREET SWELL R 8 RESIDENCE v 54 HEWITT, ST. E APPROXAMITE LOCATION OF EXISTING GREY WATER SYSTEM EXISTING SEPTIC TANK PROPOSED 5 INFILTRATORS OF GREY WATER SYSTEM PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF MWZMWM MLTH SEM CFS ' •e •.. �.,- a'Sy`'y� -,i+:i .::bmF,....9 ..ii.nC S^��^•�O���r�ya in� �'is� VE*�,.�.o-':":,'n vi:!ei: va+a•-.:.� A�i►�.•�s.;�_ -H) PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME (2A "er -e- N) I PAT- R I CC AR do PHONE SITE IACATION Shy f%° w r% '57- TM MAILING ADDRESS Fk%,W Of 008 Ob I/ 'C % 39a,/ PC HD Canplaint Natne & Relationship-(i.e, owner,tenant, etc.) QZ /91� '< _ TYPE FACILITY PHONE REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from. licensed professional engineer or registered architect. r with the following conditions: 3 S 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, gr report agent of owner agree to the above conditions. SIGNATURE TITLE DATE IMS: V&te MV; YeUcw (fin EI); Pink (Afpliam it) »- \\ .., . �. \: � � � � » «� ¢ \ \2 \t - � t� J � � \ » >« ©\y \Via� . la- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES TO CONSTRVCT-A,WATER,WE.LL please print or type Well Location: Street A dress: To ills Tax G id ` Map dock Lot(s) >> aa "t Z .a, Well Owner: re:�.? Address: Use of Well: X Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought S'� gpm # People Served -- --Est. of Daily Usage Reason for Replace E fisting Supply Test/Observation Additional Supply Drilling New Sup (ne dw 1 'ng) Deepen Existing Well Detailed Reason for Drilling Well Type brilled Driven Gravel Other Is well site subject to flooding? ........................... ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No k Name of subdivision Lot 9. Water Well Contractor: Address: iJ Y Is Public Water Supply available to site? .................................. 1 ............................... Yes No �_ 1 Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date:':.._�rpplrcant PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is'clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless. construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. t Date of Issue 0 Permit Issui fficial: Date of Expiration Title: ' Permit is Non -Trans rrable White copy- HD file; Yellow copy -Building Inspector; Pink copy - Owner; Owge copy--Well driller Form WP -97 /6-C'?5' ar Se st '69 pd Ale lit 91 POU 16'£01 69'x01 66-901 — — — — — — — — — — — — — — — - Cj ;j - - - si+ - - - - - - - - - - - - of Ar ri CLO Ar 176-oot TLS aRr Ar WO-DI Ar JV Ar fir 1.9 ar Se st '69 pd Ale lit 91 POU 16'£01 69'x01 66-901 — — — — — — — — — — — — — — — - Cj ;j PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: Located at (street): SLR TM # Municipality: h 2 G' Watershed: SO PERCOLATION TEST DATA -- witnessed by: �, Date of Pre - soaking- , '' Date of Percolation Test: 1, -O Hole No. Hole depth (Inches) Run No. Time Start— Stop Elapse Time (nun') Depth to water from ground surface . (inches) Start - Stop water level drop in inches Percolation Rate min/inch 2 3 3 eo- , 5LI -- - 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 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. Form DD -97, pg 1 of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # HOLE # HOLE.# HOLE # HOLE # G.L. 0.5' 1.0' 1.5' 2.0' WLl 2.5' 1'13 GY'1 3.0' 3.5' 4.0' t _ 5.0' (� 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.01^ Indicate level at which groundwater is encountered 4I&A— Indicate level at which mottling is observed Indicate level to which water level rises after being encountered /,. /- Deep hole observations made by: Date I i jlclir- Design Professional Name: Address: Signature: Design Professional's Seal Revised July 2013