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HomeMy WebLinkAbout4852Putnam County Department of Health Division of Environmental Health Services 2 p �'L SSTS Repair - Final Site Inspection 1 Date: > �' Inspected by: fA D L Installer: ► V i < < ra Street Location, So "Wftyttw 1r;dt,Owner: Krar.2_r II Town: Q �,:�. Vc QV Repair Permit #:_ - OctS - I 1 TM # 2 . l 7 -1 - Z 1. Type of System: Conventional 0 Alternate 2. Septic Tank Yes No N/A Comments a. Septic tank size - 1,000... 1,250 ....other ..... r 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 e. Junction Box - properly set ........................... f Trenches i. System, completely opened for inspection ii. Length required Length installed &_w iii. Pie slope checked ... ............................... iv. Installed according to plan ..................... v. 10 ft. fr om property.line - 20 ft - foundations ... vi. Size of gravel 3/h - 1 % " diameter clean ......... vii. Depth of gravel in trench 12" minimum .......... 11,1 rr oc.5 viii. Ends ca ed .... ............................... V 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 ......................... Qn� 11a L co,tAe 0.s � ta�Tf4c.�o r c. Backfill material contains stones <4" diameter ......... / V 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 ................ I ........... Additional Comments: j 1 I ' -1415 COAAf t k 4 tl - eox OJ jirAe C>'j IBS �:��� ° ^• Las �- �a �I' CoJ10�2c�Q� b Co .Lc� 0� f,or o ' l�'�RFSI Rev - 011312 Y � � ��.t_l�r!� 1 �� a Fea L� 'Lo DATE: .2 _.L' .. T4: Re: /,«belly °d �� �. .�/�.9.ueN -"/ r/..k, # OF PAGES (including this one). l 4 w"*jl /--% S/G11 0 S /dw. e s r4NE •��• Syr ►''qG c y,� E R = 2 9, 99.3 so, fr OR 0.6886 pelf 619 X OT ,GOP 12 4-07 �� I it fiREPf�4tE Ll SN'G 0 d` ,tar /o Le) „ c07 I� �. 402- 16 40i 17 (9 ` 4' a �i ,s[9rE w,W : .- ., t PoG E IY16 -22-60.4 I1r(� �Q EoGE P9Vf/>7EN) NUOSILN VZE W D SUR YICY or RRoPoR ry PteplollfeD 70 W of PCBTNRI" YN4c c PvrNAm CouarY� �!Y SeAl Inhy Z6,; llfft S URYEY SyavVN B46/NC L07'S U 16 /N 13ZAC& E ON A 1190 EN ? /TL 6D " 0SeRWoglVA A11U roP &S7W7.6 )v /ZI iN rNE PL7iV,9/?? Co N el_ FpY< 61'wlex AS i»AP eyA. t /S/' Sheet _of_� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT I "�,Oor- Street Town StIte Zip PERSON IN CHARGE OR TNTT;RVTF.WP.Tl• Date, 7 Name and Title TYPE OF FACMITY FINDINGS: !ma VA 2_sD' �'1 n�•� Mes� C,; evoS t yam. r— �x15i- I� 17 A`i J •e.. _. TNenrrrTOR • TFT ; Signature and Title REPORT RE TETVFTI RV• I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Rev. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION .OF ENVIRONMENTAL HEALTH SERVICES OPOSAL FOR SEWAGE TREATMENT SYSTEM REPA ' Internal Use Only PERMIT U YZ . Repair Permit issued in last 5 years 9/Not in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. lid Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION 1 e TOWN K#Irt OWNER'S NAME MAILING ADDRESS 1 APPLICANT Lin rn v)o i t�lthr� Sri n.� Relationship (i.e., owne( tenant, contractor) LAIJ TM # 7 _ NE �;cA 041 / DATE ��F,A,C�IILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER �,.CIJ C��. , _ ., PHONE ADDRESS ©. W61 /( REGISTRATION /LICENSE # Proposal (include a separate sketch locating the house, property lines, all adjacent wells with n 200 feet of repair and the location of existing and proposed system) vv C �3A y NOTE: The Department may require submittal of proposal from licensed professional depending on the I, as owner,agree to the conditions stated on this form SIGNATURE' TITLE 0v pie,, DATE C (owner) I, the septic installer, agree comply with the conditions of this permit for the septic system repair SIGNATURE _.. TITLE DATE (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 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 Proposal Denied ❑ Inspector's Signature & Title Da a t Ex (ration ate Repair proposal is in compliance with applicable codes Yes Cd" No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 o S /aN a .S TONE SAL 4 ► .Sle^fY ► �q. y OR 0.6806 faet f Poo E r r Ica I Q� -! h Poo E Fse, r-; Q W16 -22-4044 4YV SURY4'y alp r r I -! h i ,C 67 IJ } ,c b T Az 4,67 Lot 10 ► CtEtt ��'iRFI�'fXE ► ,4 07 y } Gar Is -S-107- I1, 40,r Ir I -C Iq COO- ` fJgr.,o �.8, `tit P00.0 - �. ��� _ 1 /ill �►. I Fse, r-; Q W16 -22-4044 4YV SURY4'y alp Y/hw DRIYE PROPERTY PUf'i4�PB,o �oR 'SRI 9 70 W 0f AlTW4#X YALL EY PU7"/VAIn COVNrYj rV Y. SUkvE)' SROWAI . 61WPs A,07"a // ry,fa t6 141 -$Z©C& E ON R MAP ENrIncD OSCRWRNA R/UrPP 4J7',,4rE." Oltffl IN THE PurN;tn CouwrY Cc ,ckxs aFFICE Rs MR? 410. PS e r r -! h Pope _ Y/hw DRIYE PROPERTY PUf'i4�PB,o �oR 'SRI 9 70 W 0f AlTW4#X YALL EY PU7"/VAIn COVNrYj rV Y. SUkvE)' SROWAI . 61WPs A,07"a // ry,fa t6 141 -$Z©C& E ON R MAP ENrIncD OSCRWRNA R/UrPP 4J7',,4rE." Oltffl IN THE PurN;tn CouwrY Cc ,ckxs aFFICE Rs MR? 410. PS e LANDSCAPE UNLIMITE, D, INC. PO BOX 38 SOMERS, .N.Y. 10589 914 - 2325623; FAX: 232 -4055 DAVE: FAX U 1 # OF PAGES .(including this one): \ \ /� � � \����� � �� \ d• � �� \�\