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HomeMy WebLinkAbout4726DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.25 -2 -5 BOX 35 04726 '• IN ti r- 11 riFsi• Is Is Is Is ,�,..� r � Is Is '' l is 1 t Is Is , 04726 d SITE LOCATION Pi PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES y Internal Use Only Repair Permit issued in last 5 years Repair within Boyd's Comers, W. Branch or Croton Falls Res. OWNER'S NAME MAILING ADDRESS within 200 ft. of a watercourse or DEC - mapped wetland r 4111 PERMIT # 4 -1 a6 - I -j LIYNot in Watershed ❑ Delegated ❑ Joint Review 124 No1l,3w t -TOWN TutIJAo, UAII6, TM# ko t Ia I & 6,v Z i 6H1 b,,­ PHONE # -q - 'S66' 704 0,4 ti }ells., lR,so(t d.b P,�i.Nar U�11b� 1� APPLICANT 1(1 tiN61 1 A i✓ Name 8 Relationship p.e., owner, tenant, or) DATE , FACILITY TYPE ja4if PCHD COMPLAINT # PROPOSED INSTALLER PHONE # q j4'7/3J-34o< ADDRESS 7 001 WgUlb 1146 CarTlh -mOr 1tlrUol- REGISTRATION /LICENSE # 1086 Proposal pnclude 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'yP. -y >i A "L .fir, (LOwg o* TN f-�I t/1.►4i+i'�s (,�%i f�� 6ti �a� , �,lrw I, as owner,aaree to the conditions stated on this form SIGNATURE TITLE DATE (owner„ septi -lin§ taller, ugre6 to °i*mpiy"i Fspelr SIGNATUR TITLE DATE 7 1 Pr000sal (installer) following 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 functio 5. No completed work is to be bac ed until authorization to do so has been obtained from the Department. INTERNAL USE ONLY r I v Pr posai Weni I ❑ n. qn -7 1 Insp5ctoei Signature & Title Date Expiration Date ,Repair proposal-is in compliance with applicable codes Yes QY No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2107 30 30 Ool �13 r ik At Pp L r UC-*F WC=4149-H91, PIZZELLA BROTHERS, INC. ucmpc-i�z SCALE: A/ T"e^ APPROVED BY: DATE: No Ili tai MAWNSY. REVISED: 14UMBEIL: p p 3•.e 'v ��J°�+'�: v,. :d:�y >• @:qn.a... sa•: y'�i':�^•,E,.,�.,� :tr�..�..b.,�?t'gce i -��L°`..rr.:y;w. °i:- .4�.. -�{•rn Ys�n�"��,i.e �..r.,�p %(:«•:•.'..+.'sue ^=�.:nS.Cw.��.i r n�.��+ 'i: "i�v•. -:M�•,.an'�.p.•�Q ��•� r., r-� d7{ � r6 ' • � �( \ �/'•~ r n ! / �s ��;i� I-•-e ., ra. <�' ..,. ..� a .•r.. . r... n-_ .,� _ . . n r-y " ,oc � ��, � -"G'° : ,:0 .., a . __ � ...... -v .�:,,,,_.......,. _ •n,. • .:� - ..... -.a, .... ... ....i.., ..S 3 .+v.•* „:..f..:... ,.ry.:`. a .-. . .. �,. .� Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site Inspection Date:.f!23 (3 Inspected by: L Installer: Street Locati n: 1040brook Owner: t i • Town: n_ _a_w�i_ Repair-Permit #:._ _� :1 -TM #:.�.�� �� —: 1. Type of System: Conventional O Alternate ErComments: Z41 2. Septic T nk Yes No NIA Coruments f 62 . i' 4A a Septic tank size —1,000 ... 1,250 ... other ..... b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. Distribution Bo i. All outlets at same elevation (water tested) ... ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches properly set ........................... f. Trenches i. System completely ed for ' inspection ft. Length required Length installed 2 8� iii. Pipe slope checked ... ............................... iv. Installed according to plan ..................... v. 10 ft from property line — 20 ft — foundations ... v1 vi. Size of gravel % -1 % " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... Pump r ed Systems 3. Se 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 0" 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: RFS1 Rev - 011312 r F r I� ,.e z ,,/&/r UC.# WC- 4149 -H91 PIZZELLA BROTHERS, INC..**. LIC. #PC -192 _ SCALE: APPROVED BY: ' • DRAWN BY: DATE: Ad REVISED. la w o � :j,,:�V7,0&'� MWING NUMBER: �n UC.# WC- 4149 -H91 PIZZELLA BROTHERS, INC..**. LIC. #PC -192 _ SCALE: APPROVED BY: ' • DRAWN BY: DATE: Ad REVISED. la w o � :j,,:�V7,0&'� MWING NUMBER: PIZZELLA BROTHERS INC CORTLANDT MANOR, NY 10567 PHONE.- (914) 739.340S / FAX: (914) 788-3738 FAX COVER. SHFFT' DATE., TOTAL # OF PAGES INCLUDING COVER SHEET PLEASE DELIVER THE FOLLOWING TO., NAM E: ORGANIZATION: FAX NO,: PHONE NO.: FROM: NAME: MESSAGE: * k' fF THERE IS q PROBLEM WITH THlS .......... . ....... TRANSMISSION, PLE 6 CALL AS CALL THE TELEPHONE # LISTED ABOVE, PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PRQPOSAL FOR SEWAGE TREATMENT $X §TEM REPAIR � w :. • _ _ ..�: - _ _ I- ternal Uea €)tidy- PEE MIJ, # Repair Permit Issued In taut S years El Not in Watershed Li LJ Repair within Boyd's Comers, W. Branch or Croton Falls Res. [JI Delegated Q ❑ Repair within 200 ft. of a watercourse or DEC-mapped wetland Q Joint Review SITE LOCATION _ J,-A flo j LW W-TOWN Tuts 11 ,4/16 1 TM N OWNER'S NAME ..�(j'l f bN Z i r Hlb PHONE N�., MAILING ADDRESS 1 .A iiallg,,, lu � runes U,yJIb -j (t. _ r APPLICANT Pi'LI.1.IIA I %ND' r r r Name & Relationship (I.s., owner, tenant. t ;tor} DATE 7 I FACILITY TYPE S1r�fo PCHD COMPLAINT 0 PROPOSED INSTALLER p2 Z"L� (Iw►L,t� Jryv PHONE N ►73`. - -.. ADDRESS -) 001 WOULD �Ab 6wT(11-W)T A14* 7- REGISTRATION /LICENSE #* /0 PrgoAal (Include a separate sketch looting the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposer! system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. FUh�)Ljt -t o'F s�l�)I =nr��7�c Gltrl( �atir7vt+� h,dw CeNye. p T A.0 k N om✓ t :+V b xrl,^ I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) I, the septic installer, agree to comply with t t� )conditions of this permit for the septic system repair -�. .. _. 8]GNATUI k " `Ti7LE� pnatalter) 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. Ovw)or'ra name, She Sbeet Name, Town and Tax Map number b. Location of Installed components tied to two fixed points c. System description (wg., 1280 gad. 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 complatod SSTS repair will function. 8. 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 Signature & Title Date Expiration Date Repair proeosal is in compliance with applicable codes Yes 0 No 13 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2107 (i L.,* /I +�1�, LIC.#WC-4249-H91 PIZZELLA BROTHERS, INC:- LIC.XPC-192 SCAA E: APFRWED By_ D;PAWNSY: DATE: off"MO.. W NG NUMBER: 1114 61®� pjtt�k P'l A j. 5. _ . �.. _ P.. .... � c.i.y;, . •. ��' .$ 'a.4', g,'... v ...p .... «�. .n�-z. -. �+....va .. sv.w •. �... , PUTNT kM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATI ENT SYSTEM t owner:. Address tT 0*80V Lok 411.25 Located at (street): TM ;# Section: _ Block 2 Lot _ Municipality: �`� A4 ^ '�+ _ Watershed: SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: Date of Percolation Test: Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop dater level drop in inches Percolation hate min /inch I 2 ( 3 I 2 3 4" I 2 3 4 2 3 4 5 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation rest. hole. (i.e., < l 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 ; ;)t- TEST PIT DATA , DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES _ - - ...,,, ., _�..a' ;v. -Q,s .n-- ...o'�:::o...a� -, �" .� ...�. . _' '....,_ . ,¢:'ems . ' `:,t�,3�yo:' = �-.�::;s"C ®.� �,p:.: .:::a:::.�a�- .•:.�:.V.�i �•.a.. "..,rn �'.,, ;.: a. DEPTH HOLE # l HOLE # _ — HOLE # HOLE # HO L_E # G.L. 0.5' - 2.0' 2.5' 3.0' 3.5' Nr 4.0' S1' ' 4.5'. Gb P-iy 5.0' t°ne"�+ac 5.5' _ �_ 7.0' 7.5' - 10.0' 1 Indicate level at which groundwater is encountered SML. Seer Indicate level at which mottling is observed n ©r\ Indicate level to which water level rises after being encountered Deep hole observations made by: L Date Design Professional Name: Address: Signature: Design Professional = Seal