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Home My WebLink About4641DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.13 -1 -19 BOX 35 04641 .F . kQ r 116? ,r UL , 04641 PUTNAM,COUNTY HEALTH DEPARTMENT DIVISION OF'ENVIRONMENTAL HEALTH SERVICES c= PR0P0SAL -F0R SEWAGE TREATMENT SYSTEM REPAIR . .- _ ' '" :. -6.'t a,.. ,.�. .rte r. -. . ,. �_` .. ..._ . .� ./ � 1�M•1 !r/ / YES + / Internal Use Only PERMIT # U L( /Repair Permit issued in last 5 years hk'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 &Zf4fit4 V&JEVTOWN nav► ��`�� TM # , S� 13 —� / OWNER'S NAME LUI<E j PHONE # �sliF5r.5J$_ $57( MAILING ADDRESS 11Z P 91f D11- C– fill F . . APPLICANT S A Name & Relationship (i.e., owner, tenant, contractor) DATE / FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER PHONE # �/ �/ 9ey / yelx ADDRESS �REGISTRATION /LICENSE # 4Z,?c) 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 stated on this form SIGNATURE, (owner) I, the septic installer, agr co SIGNATURE (installer) Proposal approved with the followin< TITLE DATE %o pply the conditions of this permit for the septic system repair _'",""TITLE DATE i 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 backfilledyntil authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pro US I A p ve Q� Propos Denied ❑ <<�iTV '( ,�,` GLq,. Za 'L q 2 o 113 Inspector's Signature & Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes 0" No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 W� r mitt cl 4115 J26)t,� J .,y Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Final Site Inspection Date:. �.� iZ Inspected by: OL Installer:. Street Location: I 7a\A- L Owner: Ci Repair Perinit 4: -20 , .:` T, ' %-TM 1. Type of System: Conventional ❑ Alternate ❑ Comments: 2. Septic Tank Yes No N/A Continents a. Septic tank size - 1,000 ... 1,250 -`;... other; . 1050a,l , Pis �Ffi s 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 / V e. Junction Box - properly set ........................... f. Trenches i. System completely opened for inspection ii. Length required Length installed iii. Pie slope checked .... ............................... iv. Installed according to plan .. • .................. v. 10 ft. fr om property line - 20 ft - foundations ... U/' vi. Size of gravel' /, - 1 % " diameter clean • ........ Vr vii. Depth of gravel in trench 12" minimum ......... �✓ ..-viii.- Ends capped - _ g. Pump or Dosed Systems 3. Sewa e System Area a. SSTS Area located as er 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.* 5 � � e t�s Uj\' 9 ` �C aPe Co rrW' 1Y O nA& as OLCCo r c�, �o Po —rsAt'� Proposal, RFSI Rev - 011312 i ,Pz�� PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES - 2ry2�5�-- 3�8`3�8�/•2�25� { -� 3�8+33/.225- 3�6+ry4yly�_ �j.._. _ 9}-R j+�' 11J`, �L �/iC �7GYYtiI G 7JI�7P 5Y►711'11 L�C1C 's i' i =i{i, y.:a ;wi •. ve .y ':!l. • _ `+'': -f' OWNER'S NAME 4" k a C'_ i Z 18 E R 1 0 PHONE SITE LOCATION uF:F J3h& &Fk!57, 1 MaLF_ AtearN -vr- kett•re mo �'- %- MAILING ADDREss onga._gg sr e2pud3 sOX IM P(.47oV#M V11L1-6Y 'A1-)6 161:79 PERSON INTERVIEWED L L4 K I� @_ l L J A e R.?'D - 0 w N'l�r PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE 14_a o , / q R': TYPE FACILITY Pg i ATE i l=RM L�r Lid t q, PROPOSED INSTALLER ;j y/t iV d 1 Z AE 471-1 PHONE &2,? 6; 7 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. C1-0e ; &9D Fri W5 AND oat Z JAI Mg -raft RAKPL.i96 MA',vr s SPrcr 'TAMk Inspector Proposal Disapproved ggF & Title U '-nA�, L4 j y toposal approved with the following- conditions: 1. Procnrenent 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 �jrepor�ted agent of owner agree to the above conditions. SIGNATURES C.t ,��1 TITLE 'IFS: V&b.e (MU); Yellow (Tcwn BI); Pink (AFpliamt) ' � c(zS ELL . :9 4 ri 4Sl 14 Mr :LLI NG- /�1 wf LL (5wAj6k - Li%1iL4C C6[.iBE�r'6 PLA, -TNnm VALLEY NEw R: -rFLncENYEAI'T M.eTAIL Stai >T /cL- r4lvc Sa�3 7q-? 1 / (5wAj6k - Li%1iL4C C6[.iBE�r'6 PLA, -TNnm VALLEY NEw R: -rFLncENYEAI'T M.eTAIL Stai >T /cL- r4lvc Sa�3 7q-?