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HomeMy WebLinkAbout4849PUTNAM COUNTY HEALTH DEPARTMENT .� DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,.✓ PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Y N Internal Use Only PERINIT #1 ❑ Repair Permit issued in last 5 years BYN60n Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated El Repair within 200 ft. of a watercourse, or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS .t17t��J� PHONE # V61-2 V- LZ6 APPLICANT ,&j -A-,Vo,,,..-,o C ©.! 7-f -4 �nr Name & Relationship (i.e., owner, tenant, contractor) DATE r 'J .4�: )LO41 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER _:aL1) z_ A_/0,WD Zc , PHONE # ADDRESS /V. 6 Corcli�ZPd P6.,/< ,J Ma, i%T , REGISTRATION /LICENSE # 4.1 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 s bmittal of proposal from licensed professional depending on the natur and exte t of the repair. OL Cowl Jk ll' ?nC A- 2 t'oo6 4o` 7rvvk rr 1 !l�fw I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE %9'.�'rzu_� TITLE DATE r^i oZC� pnetaller) Progml Rtxoved 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 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 Approved Q Proposal Denied ❑ Is ignature Title ) Date Expiration Date ls. 54�t_ ( Repair proposal is in compliance with applicable codes Yes ❑ No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ii 419- ------------ too ------------ lfvn ---------- - it ----------- - - --- - ------- -- ------ p -7 C>()' _.iiE � . .......... PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROOOSAL IFOA SQVME'TREATMENT SYSTEM REPAIR U U Repair Permit issued in last 5 years U Not in Watershed ❑ ❑ Repair within Boyd's Comers, W, Branch or Croton Falls. Res. ❑ Delegated ❑ ' ❑ Repair within aoo ft.ofa watercourse or DEC nWped wetland ❑. Joint Review SITE LOCATION OWNER'S NAME (MAILING ADDRESS APALICANT Name & Relefiomhlp O.e., owner, tenant, contractor) TAB #�io `�—ge PHONE # gY,?-LZ� 6 DATE ,fi'/ 97 FACILITY TYPE PCHD COMPLAINT # . PROPOSEDlNSTALLER'�,��/t1n�a PHONE # ADDRESS k,,&k" y 1 _ REGiSTRAi`ioN !LICENSE # A"`�, S/ ng e. oase, Pre lines, aracent wells s n 200 luri a sea t h Pest 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 � � f� TITLE (Jiynat,- DATE 6 // i, the septic instailler, agree to comply with the conditions of this permit for the septic system repair SIGNATURE"'""" TITLEG�.-► DATE Ir (lt>siirer} f'r4 , 1 #p�oY� the f0(iowrina condiQor►s: 1. Prdwrement Of artV.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. Concrote septic tank, clot) 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 SST5 repair will function. 5v No completed work is to be backfilled until authorization to do so hasv been obtained f m the Department. INTERNAL USE ONLY Proposal Approved ❑ Proposal Denied ❑ Inspector's Signature & Title Date Expiration Date Re `r proposal Is In compliance with applicable codes Yes '0 Na D COPIES; PCHD; Owner; Installer PC -RP 99ML Rev. 2107 ... .�wr r...+i y?y 'env f -7 J T . PUTNA34 COUNTY DEPA.RTMI ENT OF HEALTH DIVISION OF ENVIRONNtENTAL HEALTH SERVICES DESIGN DATA SKEET - SUBSURFACE SEWAGE TREATIMENT SYSTEM i Owner: 1— Dev,ten s �t�` Located at (street): 3J &-�Ck Nlutiicipality: w�`0`s^ V� Q Address: TIM 9 Section y BI ck Lot Watershed: 1� SOIL PERCOLATIOiV TEST DATA ' Witnessed by: Date of Pre - soak -ing: Date of Percolation Test: Bole No. - Run Trio. Time Start — Stop Elapse Time (min.) Depth to . water from round surface (inches.) Start - Stop Water level drop in inches Percolation Rate min /inch 1 Z 3 4 I 2 3 j 4 3 � I � 2 3 4 l i 2 3 4 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation rest hole. (i.e., < 1 min for 1 -30 min/inch, < ? min for 31 -60 mitvinch). All data to be submitted for review. 3. Depth measurements to be made from top of hole. Form DD -97, ps I of 2 TEST PIT DATA . DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # G. L. 0.5' 1.0' 2.0' An 2.5' no't 3.0' Lwrt 3.5' 4.0' 4.5' N `� 5.0' 5.5.. 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 10.0' HOLE # HOLE # HOLE # HOLE #_ Indicate level at which groundwater is encountered NOR P� Indicate level at which mottling. is observed oRQ Indicate level to which water level ris s,after being encountered Deep hole observations made bv: M, 81 4 Qe Date 8 Design Professional Name: Address: Signature: Design Professional = Seal