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HomeMy WebLinkAbout4587DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.06 -1 -25 BOX 34 04587 J6 .. r r IN, III: INN ?i- IN I . .Ij L . ) 4 ANT N ;� T io NJ I • , a rl ' ON , I � - 1 N �.: r -h 6 I . =1 No IN ,_ , 04587 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR �: .:a' ?°� "•, -y6,;. •c ks•�y .� ;�'T,' �;L.,:ae .wr'_ti, �,� . _;7 ... -� 1 -. r ;. � a..`sr� <-+= %es :: �=,=e is •b" ^� '.a.'K' �. s �- ..�.:,s ": •�F+ >:: �a,�,._�;7 .,e,-ti' � ',.- .+... x. YES NO/ Internal Use Oniv PERMIT # 11 -►y' I - 1%4 I ❑ Repair Permit issued in last 5 years L" Not in Watershed ❑L.�J,/ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated El Ild' Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION a�/ aPOV:�S/ �% TOWN TM # OWNER'S NAME rTN 3%je . J � /V 01415 HONE # fV MAILING ADDRESS �/ ��C'0 ✓�5� P /Gelj -' APPLICANT / m P, i n s Name & Relationship (i.e., owner, ten t, contra or) ' - DATE 2&j FACILITY TYPE ;DE-5 ___PCHD COMPLAINT # A11A PROPOSED INSTALLER ©�1�iL�l S L/9x/I�SC'u d'J/IrJ PHONE #S ADDRESS A &Y �% S)79y.6 Ca,, REGISTRATION /LICENSE # /0 Pro osal (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) - Fo�_o =�a !� NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. S - _ _ . dnf/1 //9(�!r'1 �g�✓/i0'G�•,� ��,CV6�v7i�l I, as owner,agree to the c itions stated on this form ' SIGNATURE TITLE DATE (owner) #; the• eptic•inst r ee- to•.comply with the; coD diti.ons.of this permit -for theseptic_system.,re; o....p ate r... . a. ev- y..�. -. �; :• _ � .. . - ....� ..�., .. .. ..». -,xCo. 1:' �w..�...�.. ..... bz ...v.... SIGNATURE TITLE DATE (installer) Proposal al2proved 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 duplicdte shoes 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 System repair to be performed in accordance with the above proposal and conditions 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. No completed work is to be backfilled until authorization to do so has been obtained from the Department. 3. 4. 5. / INTERNAL USE ONLY Proposal Approve Proposal Denied 1:1 Inspector's Signature & Title Date EApiralion Date Repair proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ;/-; /,/ I/ ' .. .. .�. .t...... ...�..r•t +.... tv �.. .. �.4•....'t \'ti.' +1r,. .... tiYJ1' --�. � • ' I -: .•: C•S:•�.$`�.. ei.rrysn<s•- +'- ,ce.`� °- .'1�r, - . ":o -;'. *r`Y"sirt�. > : -v->:; �.':; a <:: '.':�..r -; ,a ,:cs .-.'p'�56 .:- .i`d__.�R�YF 771e- w►:."='3vO =o .•:vs v--- 'C'.•.: : &: f; �:L .Q; `R•E &' � O n/ fFN: ER O �� ONG EACH F /ELD /S 30 vt/lo4 � 6 1 O f Now ®R foKa1,�F t y EJOW.4 0 F/iv/vcRry.. T 7s r ,os ti s S��: �•,se s ,� T7 I IV bo'-414 i L tY `Our flee5 VJ cc LOS' 1 2 CD .. `-GY .-.� qq ..... -�. 4- •....y. -_ . --. +-e -... _ • fin-. . d tee.- T...� .. u+S ... .�j •�. , .. _ - �. . ,� �.rJ�a�q.'. .. �..p ._. -• ...3:3 6/� i NN 15ASTERLY S,nE OF S 8 °43�� ®Ow t 9.08 va o n St Putnam County Department of Health Division of Environmental Health Services SSTS Repair — FinUSit Ins pection Date: Inspected by: Installer: Q i-- Af-j Street Loc tion: g 40 Owner: T ©wn:.�+ ✓ - - Repair -Permit #:,..mil `"I /_ t : �- ,TM #: .a... G. 1. Type of System: Conventional ❑ Alternate ❑ Comments: 2. Septic Tank Yes No -N/A Comments a. Septic tank size 1,0— ... 1,250 ... other ..... b. Septic tank installed level ...................... c. 10' minimum from foundation .................. 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 — properly set ........................... f. Trenches i. Systemcompletely opened for inspection ii. Length required Length installed iii. Pie slope checked ... ............................... iv. Installed according to plan ....... :............. V. 10 ft. from property line — 20 ft — foundations ... vi. Size of gravel 3/, - 1 '/s " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... _ ,.. —..4.. �._ viii: • Ends g. Pump or Dosed Systems 3. Se a e System Area a. SSTS Area located as per approved plans b. Fill section — c. Distance from water course /wetlands 4. Overall Workmanship 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: RFSI Rev - 011312 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR ❑ Repair Permit issued in last 5 years Not in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ (id' �Repair within 200 ft. of a watercourse or DEC- maPPed wetland ❑ Joint Review SITE LOCATION af/ ROVX� �j Tnwnl l �® TM A it ;. / /'~,n;P OWNER'S NAME PHONE # MAILING ADDRESS cQ/ pieOV 95i , Al Z APPLICANT on, 1 % /7 5 Name & Relationship (i.e., owner, ten t, contra or) DATE _ FACILITY TYPE PCHD COMPLAINT # i�- PROPOSED INSTALLER P.)MIOY; /) 5 L AU650it //;/7,q, PHONE # ADDRESS 0Y �'JQq,� (,%(.�' REGISTRATION /LICENSE # 10 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) +0 0;710 /a J Q q c f • C� -�- NOTE: The Department may require submitt al of proposal from licensed professional depending on the nature and extent of the repair. _ I, as owner,agree to the stated on this form I, the septic inst r ree to comply with the conditions of this permit for the septic system repair ,.:.�. SiGNA T iJRE - — TITLE /- DATE— (Installer) Pro oQ sal apporoved 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 dupli to 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 Approve Proposal Denied ❑ . /J. 4- Inspector' Signature & Title Date EApiration Date Repair 2roposal is in compliance with applicable codes Yes ca/ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 D, uo Q.A P.Y* 11 #9 VJ-3 JA fop L 0'7 1�7 ,4 vo I A4A- 4 & 4G m c / 7-f - f,2. 4 4*1 A-,- ,;( v 7, 09 z X.Z. ;11,ld IN 9 '.•:Jt?•L`.`.....or •+yid >i<tii�.� -T .�.�v •'f.r.. :A; .< :.s:..: ,Y:- r1.:= .,'q..a -. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: V80 r� r Located at (street): TM # Municipality: C, ANO Watershed: SOIL PERCOLATION TEST DATA d Witaeased by: '- " ;: & Date of Presoaking: � Date of Percolation Test: 440-A AV Hole No: Hole depth p (Inches) Run No. Time Start —Stop Elapse Tie (�) Depth to water from ground earface (inches) Start- stop Water level drop � inches Percolation Rate miin/inc6 t ,fl 3 •. 4 5 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., :5 1 min for 1 -30 min/inch, < 2 min for 31 -60 mWinch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97, P61 of 2 TEST PIT DATA (DESCRIPTION OF SOILS ENCOUNTERED IN TEST BOLES t 9 xp.m- H4- it-�a ;,. "Ol EN- k.o G.L. 0.5' 1.0' 2.0' 2.5' 3.0' 164M 3.5' 00h/ 4.0' C 4 6 ed 4.5' lGl &"4 5:5' 6.0' 6.5' 7A' G G 7:5' 8.0' 8.5' 9.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: D, 1k; Date Design Professional Name: Address: Signature: (Design Professional's Seal Revised July 2013