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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 \ M ` v.-�� DEPARTMENT OF � | - eumm COUNTY Nov mD1 Y o19 \ M ` v.-�� DEPARTMENT OF � | 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: pio�ja's ff jj CL> 14 So oV'R_r le�tje,f 4D bC;:ff t2 C®u�k S� no� be^� I R]FS1 Rev- 011312 U {: I jt�I�� a6h 4o Screw If 5�AT, ��� {r- C9 Lit Av IE NE Ao� LIE 110' S�PA�t�oN "4WOC-NIAW� s WO ►.1. 5Ef'RRt� 'rte" 15 LEE Avg 3vF—wAq kl u 7 URwEv�s�i �re�iNB.btt S --k OA (P UG E AV IE NEt:1_ lk Its AVE Rt�'fEOt�! P� v E ti u pR��Ewq� S ARr�o�1 WIE%6HBoO S llti — ti ouD 60,tite)r-,\ P Ky -ro-f\y, —. A- -DYDP lboyle.5 2 D� 60116 `� c�u-t o� 'saxes ' %f* doe . � � � � --��pe � �� �d ,j a- sue& 1 Geneva Rd. Brewster, W 10509 4:: _ " A i. j: �; • Phone- 845. 808 -1390 Fax - 845- 278 -7921 HEALTH DEPT. Web address - putnamcountyny.gov Fa)( ( (� l ¢.l 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 -Re: C L e cc: ❑ 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: I T-IZ7�Z rr,, it rn—,,-1:r:--f ir ;.q-np rienrli smr:1 "- �' U. �i:a, awN.•___:.M+ WNwuwu. wwM• Id��rY3ai: a' u. �i^• LIi .YW4W'•SJaA':1N+9ivrd4WlG114GP 1-0•. i. �Wl1 HYTYt• IKI/ Cy3Y16fbu' ifnV 'A�lYillWilYiii.i:�?C6lJ�i+J:K •.. agvullu' va6��.+ K�J ¢14T:4Y` +n:..uNalu..o.wn.xiw�nw �.�v+u a': ,LL • � �•wnJ+� v �i1...�.+N�t.�.uf314'JMr4 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: