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PUTNAM COUNTY HEALTH DEPARTMENT vqc i 5�t'
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SOP AL'FdR S �'Vr4C ,T i T3�ENT�SYS'TENI REPAJR
Use Only . PERMIT
❑ 19/1 , Repair Permit issued in last 5 years &�Qot in Watershed
0
❑ 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 �i _„ J ;�� NN v .71q�1VALi
OWNER'S NAME ,Sit•ff7iS ,. A2t°4A: AC65Tr'
MAILING ADDRESS
APPLICANT 140 vv
Name & Relationship (i.e., owner,
c Lot- 1 V
TM# giig J - II
PHONE # "/t7786 6 > 11
PV kg /n,y4LL,li. ly.y.I`es i
; ATE FACILITY TYPE �J12 rl-t PCHD COMPLAINT #
PROPOSED INSTALLER 4 `�%r p l �QL PHONE # rs zsi(.. �s�i�
ADDRESS REGISTRATION /LICENSE # 10 Yj
Pr sal (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.
c14r.;0
I, as owner,agree t L�he nditio ns stated on this form
SIGNATURE TITLE l DATESr
(owned
-A-, the septc irtsta'fer agree to comply with the conditions of -this permit for the, septic system. repair
SIGNATUR 6�vvicj TITLE 46 -CWT- DATE � � ��' //'Z,
(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 oration 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 Approved Proposal Denied ❑
Inspector's Slanalure & Title Datd Ex iratio Date
is in compliance with aDDlicabie codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Yes
Rev. 2/07
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PUTNAM COUNTY DEPARTMENT OF HEALTH
:4:.:•`.PU Pi
FIELD ACTIVITY REPORT
N A MF.: �C�S-�a Tel:
Street Town . ,State Zip
PERSON IN CHARGE
Name and Title
TYPE OF FACILITY:
FINDINGS:
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Signature and Title
REPORT RFCF.WRT) RV:
I acknowledge receipt of this report: SIGNATURE:
02/96
Title:
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL MR SEWAGE DISPOSAL SYSTEM REPA
IR
C14NER IS NAME s Irs 0 W 6S cze PHONE
( I 3.
SITE LOCATION 01,0 TV JU4pi KC' TO S
MAILING ADDRESS ;4v,1 4si V A-- L k:(L.
PERSON INTERVIEWED PCHD Caq:)laint #
9/1
Zt Name & Relationship (i.e, owner,,tenant, etc.)
DATE TYPE FACILITY tlze
PROPOSED ASTAUM 4 GRA-C-- C-X-7- PHONE A-416'—
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
Nam 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.
2A ?41
Proposal 0&, ed
1.
2.
3.
Inspector's Signature & Title
Proposal Disapproved
x)sal awroved with the following conditions:
Procurement of any Town permit, if applicable.
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 curponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
lq,loll4z
P Date
(e.g.,house corners).
three precast 61 diem. x 61 deep
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.
SIGNATURE Jr TITLE
OMS: Mite MD); YeUcw (TIkn ED; Pink (AppUamt)
PATE 46
PUT',N'A-'✓l. COLTINTY DEPARTNIENT OF HEALTH
DIVISION OF ENIVIRON-,-IENFT-kL HEALTH SERVICES
DESIGN DATA S HE- t T -* SUBSURFACE SLEWA GE TRE AT tiIE"NT S --'/S TEIM
L
Owner: Address: 22 Peej,(!skyz�/o /�„i T�
Located at (street): TINI 4, . Section: Block Lot
Municipality: 20q�A&o Watershed:- 1"llull.,0
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre-soalcin,,7. Date of Percolation Test:-
N'o r es:
I
. uls«. �: w: uimswi, t ,w::wiAa:u:.l...u�4mrtu�;4.'ratY •. .
✓:.`::,..:. n. w. l `- __....w....n.i�.,.i...w.m:.wr ... W.7 aUf x.: u. fwW»'J e'( W, x. u,:.: wul tiYG. LLWTie Yuu: Y: N. idV.. J?.:. fi iu.... wx�v. uuvw.,. v.. �. u. Yv�W,.. �.' N4.:- ..u.w�.,:.,...n..0 «..en.,.
Lndicate level at w1lich poundwaier is encountered
Indicate level at wLch -mottling is observe,-!
I_�dica.te I.evel to which water level uses af-Le being'�ncountered
Deer hole obse. rations made b-,;:
Desic -m. Protessiorial N -&-n',:
A,`dre ss: —
.Date
TEST PIT DATA
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y ,�I
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Lndicate level at w1lich poundwaier is encountered
Indicate level at wLch -mottling is observe,-!
I_�dica.te I.evel to which water level uses af-Le being'�ncountered
Deer hole obse. rations made b-,;:
Desic -m. Protessiorial N -&-n',:
A,`dre ss: —
.Date