HomeMy WebLinkAbout4853PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES a
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR ' 12-
YES NO Internal Use Only PERMIT # Z_-
❑ epair Permit issued in last 5 years Not 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
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
DATE I k I l??! I'2
PROPOSED INSTALLER R[D w r Wfll? V PHONE #
Lee Rv2. TOWN -pt &[�O M Vall to TM #
r
Carne 10" PHONE #
(Qlq) 3RD- �b9�-
L.6
ne i
hip. (i.e., owner, tenant, contractor)
FACILITY TYPE PCHD COMPLAINT #
ADDRESS REGISTRATION /LICENSE #
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 t(te�� pair.
5� St'Q.G pans
CAIT e4 1_
S 14
I, as owner,agree to the conditions stated on this form
�OrYY�bwi`112.v
SIGNATURE TITLE DATE )
(owner)
I, the septic installer, agree to comply wit the conditions of this permit for the septic system repair P
SIGNATURE TITLE DATE ItlI,�I jam_
(installer)
Proposal agAroved with the foil ing 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 backfi until authorization to do so has been obtained from the Department.
7 INTERNAL USE ONLY
WInspoes oved IT P�op i aI Denied
. �� t nature & Title Date Expi ation Date
Repair proposal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
eumm COUNTY
Nov mD1 Y o19
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DEPARTMENT OF
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eumm COUNTY
Nov mD1 Y o19
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DEPARTMENT OF
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Putnam County Department of Health
Division of Environmental Health Services
SSTS Repair - Final Site Inspection
Date: t'L� 3 I Z— Inspected by: Installer: 0 LJ V\,L r—
Street Location: 4 LQA_ Fly G Owner: Lo' C% P n
Town: Alle Repair Permit #: • _ -12 TM # C `�� -7
1. Type of System: Conventional ®'Alternate O Comments:. _
2. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size 1,000 .. 1,250 ... other .....
b. Septic tank installed level ......................
10' minimum from foundation ..................
d. Distribution Box
i. All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
V
iii. Minimum 2 ft, Original soil between box &
trenches
e. Junction Box - properly set ...........................
f. Trenches
i. System completely ened for ins ection
ii. Length required tj I Length installed
iii. Pipe slope checked ... ...............................
iv. Installed according to plan .....................
✓
v. 10 ft. from property line - 20 ft -foundations ...
vi. Size of gravel' /. - 1 % " diameter clean .........
vii. Depth of gravel 4n, trench 12" minimum .........
✓
viii. Ends ca ed ...............
g. Pump or Dosed Systems
3. Sewa e System Area
a. SSTS Area located as per a roved 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 <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 .........
g. . Erosion control provided ............................
Additional Comments:
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1 Geneva Rd.
Brewster, W 10509 4:: _ " A i. j: �; •
Phone- 845. 808 -1390
Fax - 845- 278 -7921 HEALTH DEPT.
Web address - putnamcountyny.gov
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To :. A Lo, From: At L Let
Pages: `Z �i�nc�k�.i C e ✓R!'
Phone: �� l �� 3�2 -5 5. 4' 7 Date: 112 ��12
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❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
• Comments:.
I
PUTINNANI COUNTY DEPARTMENT OF HEALTH
D MS I ON OF E NIVIR 0 -INIVIE IN T AL HE Al. TH S E R VI CE S
DESIGN DAJA SHEEFT —'SUBSURFACE SE -WAGE TREATIVENT S "L'STEM
Owner; kddress: Let Ave
(street): Let. Ave.- 62,1%10c, -7
Located at TTVI Section: Lot
KI nicipalit
U Y: Watershed: -
SOIL PERCOLATION TEST DATA
Witnessed byt
Date'of Pre - soaking Date of Percolation Test:•
F
Rio. o.
kur].No-
Time
Start -
Stop
Elapse
Tim e
(min.) I
Depth to
water f-,Q'M
a-round
Sur-face
Start - Sto'p I
Water
level drop
in inches
Percolation
Rate
min/inch
2
.3
5
2
3
4
2._
J
- ------------------
4
j
4
Notes:
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TEST PIT DATA
_......DESCRIPTT N-- '1 C Q U N``TCS —.....
HOL= R HOL = R
Indicate !eve'.• at which zroundwaier is encountered A.Ae,
Indicate level at w icnmottlin` is observed 0c,
L dicare level to which water level vises arfter being encountered /V
Dee^ hole observatiorL made by; _ Date tl 2� I �-
Desip Pro ess-onal N(aml-:
?.ddre ss:
SiM, at:,re:
HOLE = HOLE
C.L .
1 J
LC�w•1
2.0'
1�^
z.51'
Sa��
3. 0'
W i
Sernt
3.5'
``
5._
8.0'
c n'
In 0
HOL= R HOL = R
Indicate !eve'.• at which zroundwaier is encountered A.Ae,
Indicate level at w icnmottlin` is observed 0c,
L dicare level to which water level vises arfter being encountered /V
Dee^ hole observatiorL made by; _ Date tl 2� I �-
Desip Pro ess-onal N(aml-:
?.ddre ss:
SiM, at:,re: