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HomeMy WebLinkAbout4753DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.26-1-43 BOX 36 I INS -I.:. mq r m r INS IN I IN my6 41 ji T. a NIN ' - �1 '' ■ r I ON 1 T y 1 04753 PUTNAM COUNTY HEALTH DEPARTMENT O_ �O DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL -FOR SEWAGE TREATMENT SYSTEM REPAIR E� SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT Internal Use Only PERMIT # R— 5-- Repair Permit issued in last 5 years UVNot 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 11i0n/3dv S T TOWN TM # S°dNIA &e-d s to z- PHONE # rrr aAil- & A c,F. v� Name & Relationship (i.e., owner, c. DATE � - Z�j- Z FACILITY TYPE ,f'Q S PCHD COMPLAINT # /✓U PROPOSED INSTALLER h4AA,,,.,/ Exc ,,.lT , , TIC PHONE # fJ(S'2,y5 -,7YaY ADDRESS IY3,�6„/ REGISTRATION /LICENSE # A/ 7 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. -7 . s .1'a / I Z %„ le ,,, , i ,._ ✓ e %;s 1Ti2 /h ✓pia, le Ss I, as owner,agree to t conditions stated on this form 4VA—W SIGNATUR TITLE DATE Z©/ L/ (owner) I', the stoic insta%r, ogree:to cpnftioly with the. conditions, ,of ?his permit for the septic system repair. SIGNATUR E TITLE DATE I- Z?- &) / (-/ (installer) Proposal approved with the ollowing 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. iN 1 ERNAL USE ONLY Proposal Approved Proposal Denied ❑ ImAi&tort Signature & Title D to E-*iratioA Date Repair proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 0,.;, k, IP cc) 0,.;, k, POW i , s i t a ` lelc Iris : -- ry I I i t ! 1 F •_ jof ZIP ti IL � ! � � � I �i�`_— � �.- �.. � _ I cal. !)K..d•�'�' __ �..._...!_ _. �1._... .__•_. --� POW Via! I 1 Putnam County Department of Health Division of Environmental Health Services SSTS Repair - Fin a Site Inspection Q Date: y �� Inspected by: (,e ` _ Installer:�� �X L Street Location: jjj S Owner: w I c' rui .l _- - "'_ Rpraii Permit_ #:,: 5 4 J14fit: 1. Type of System: Conventional MrAlternate ❑ Comments: 2. Se tic Tank Yes No -N/A Cc a. Septic tank size -1,000 ... 1,250... other .... . b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. Distribution Box L 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. Stem completely opened for inspection ii. Length required Length installed ` Hi. Pipe slope checked ... ............................... iv. Installed according to plan ...................... v. 10 ft. from property line - 20 ft - foundations ... C 16t 3�jj vi. Size of gravel' /. -1 �/2 " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... . o . : `' ... • .. -.. Viii:- Ends c' e-d - --- . . ............... .......... _ v , .. :� Pump or Dosed Systems 3. Sewa e System Am a. SSTS Area located as per a roved lens 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.. I ........ g Erosion control provided ............................ Additional Comments: )rnments :�:.' '�:� ._. a l= ....:'• RFSI Rev - 011312 PUTNAM COUNTY DEPARTMENT Dip' HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TE 'I MG ATT ENTM: ® Michad I Budzinaki, PE 0 Jogep h S. Fairsavefig Jr. All Information must beIggy completed prior to any sckedoding. I[D&te: 8`70-2,0y Engineer 0r Firm: ��� �� �3� �, �� � _ Phone #: F'YS`z y - 7 ` o Y Reason: A Deeps We Road /Street: �r T Town: 4 Tax Map #: Ile �118�D6�9199�fl ®Dfl: Owner: -e mo&cU .i ,y e � ❑ Project not Withilm NYC Watershed Lot M NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF $OIL 'fl'II< $TIING iI ]Proposed SSTS within the drainage basin of West Branch, Croton IP'aliB, or BoydB Corner reservoirs. ® Proposed SSTS withIW500 feet of a reservoir, reservoir stomm or control lake. D . ® Proposed SETS within 200 feet of a watercourse or o DEC wetland. ❑ C1 Proposed SSTS design flow greater than 1000 gaftnalday or SPDES ]Permit required. ® ® Proposed SSTS for a Commmerclal project. it is the responsibility of the design professional to provide the above leformatiou prior to Boll testing. This Department will determine the NYCDEP project stetui 9 , (Joint or Delegated) based on the response- If you answered yg to any of the questions, KYCDIEF must witness the-soil tests. This Department will coordiu,ste a mutually suitable time for field testing with the Design Froffessuns and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent Information indicates NYCDEP is required to witness the soil feats, it will be the sole responsibility of the design professional to schedule re- ewitneuing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: TIME' COMMENTS: (FIEWTEST)m 7113 +y w�._eea'W q -.a ;.o+ :�yY..�.t.: _.t .a.�,,.e•a:'�':� "� ... . '] .w. �.s6a�y.V- ^..`i- ♦-..:A < -'1�^. G:1 - Y .._. F, f�.�- .a.- •C�..�.:�t..�. ..� .. ♦ 4.. �F.-�� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: / ��I� �' Address: , 9'� Located at (street): TM # Munieipality: lif lam U4 f �04 Watershed: SOIL PERCOLATION TEST DATA r !' Witnessed by: x Date of Pre-soaking: C� Date of Percolation Test: -X /-4/ Hole No. Hole depth (Inches) Run No. Time Start — Sto p Elapse Time (min.) Depth to water from ground s �= Start - Stop Water level drop in inches Percolation Rate min/inch 4 1 2 3 4 5 1' 2. 3 4 5 I 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., 51 min for 1 -30 min/inch, < 2 min for 31 -60 mirdinch). 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, ENCOU EIIBED IN TEST HOLES 4uca ..v —•:3;, :S'IrMQJ y -P rJ.c- �:rL �iG tF . G, S,01LEP ..' , i„_ r -, .s u", SA�;v. M,4,.c �Q'�' LG 0 `t G. L. 1.0' 2.0' 2.5' G 3.0' arm 3.5' fi 4.0' fv� 4.5' 5.51. 6.0' [d 5.5' 7:5' 0.0' 9.0' 9.5' :10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered f� Deep hole observations made by: rr) r ; I Date fF , /% r � Design Professional Name: Address: Signature: IIDesIlgm Proffessn®mmPs deal Revised July 2013