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Home My WebLink About4867fP ow // �, „•. ,,. �UTNAI1/��;COUNTY I ;aLTN DEPARTMENT DIVISION OF E"VIRONMENML HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES NO Internal Use Only , PERMIT # 1�' !`( 0 ❑ Repair Permit issued in last 5 years : ' In Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. LD Delegated ❑ Repair within 200 . ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION ` ' � ,� TOWN I �� Ii,�LF -I TM # 77/ ". OWNER'S NAME All SSA, PHONE# $4f zip - 9 2 `_ ,MAILING ADDRESS'7�( S" APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE 'mss t t FACILITY TYPE • (' PCHD COMPLAINT # PROPOSED INSTALLER ° a �, 4btmr�k; SQh 'xQ PHONE# CC qA 0757 R, tt ADDRESS jet l'u►c04 Ay, REGISTRATION /LICENSE # IDS �3 Pro osal (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 xtent of the repair. I,.as owner,agtee to the conditions stated on this form: _SIGNATURE , �G TITLE C;WNZ�f- DATE (owner) 1, the septic installer,agcee to comply with the conditions of this permit for the septic system repair SIGNATURE �� TITLE Pre -5 DATE OC 10 � O 1.1 (installer) —,!` s:g��d �y 0. l.aeo�g�sf t?c. C'mn�t c -��°. Ga „�, fQ 6.� re or�e•►r� �Q, M, r.%. Pro osal a roved with the followin conditions P PP 9 • 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. Iristallers' 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 durationYa3�ch the completed SSTS repair will function. "tia= 5. No completed work is to be backfilled until authorization to do so has been obtained from tfle.D�partment. WS 1 INTERNAL USE ONLY Proposal Approved El Proposal Denied El t; •.., ..�, -- � p ,/�- icy f . nspector's Signature & Title Dater Expiration Date Repair proposal is in compliance with applicable codes Yes C3' No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2107 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES}_,:;,! - 1t• ;_ PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES NO Internal Use Only - PERMIT # -,xK. � = �� ►` "` "" ❑ Repair Permit issued in last 5 years E0 _ of 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 Z7 g&eg ' T TOWN f fry• U,�}[.LX1 TM # g� - OWNER'S NAME 11ets � A/I S19-k) PHONE # ($ys) g7p, -9 MAILING ADDRESS 2-77 A AP-4154 Ste' APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE $ . PCHD COMPLAINT # PROPOSED INSTALLER (Ar-G, D� PHONE # ADDRESS l 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 anKv,ra-, xtent of the repair. T)F-.s -t 6tj I, as owner,agree to the conditions stated on this form SIGNATURE % %4 ,9� TITLE O(AJ1VXX- DATE 14 161 -1�1 t. 11 (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE (installer) % 6t 51gr►e�a/ day ci liccaSr -�i �'?G Con�oac�r►r-, G'o�r �0 6t t^,eZ%zv�^+1�Q 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 ❑ nspector's Signature & Title Dat Expirat on D e Repair proposal is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ::«:. ti•..:,.... w... n..«.+ r'« �.. n«: o....««... r. �:, o... 4:+ �ru. u., sw:. W.e'wa..oY.gaula:i::�««.al.w:t 4' tv': u.. ww: w�lw4ati'. rxtuac: ww.. �uiYG. uvYouaiul' rbL; 1V..+' na..+ J"•: es... ux. w« �. ca>...;. v�.• i.::. v« e•., rv>.«:.... ni:. �. �: n:. n..«:.... w., yu. u..:•w...u._.�J.;..d.,•..�.•.w rt t - \:Y G.L L. 0.5 1.0' iJ 2.� 3.0' 3.5' d ,J 1• .v 5.� n� J•J b'. v 7.0' v TEST PIT DATA DESCRIPTIO`i OF SOILS EvCOL'r'tN'TER.ED I TEST HOLES HOLE = Z- I !jcC- � Iex CANA-- HOLE » 3 0� It90 L(iC( 1p /C/ Q HGL= R � rGL= -5 ex VIA-- 10.0' Ln i CdL e level ar which poundNate- 1S %l 0 / Indicate level at which mottling is observed o I ,— 'n - ^r tree �� / I_!dic3t° Level to ��`iica water [eve', rises �,.., be,!.� �:!..orr__ rL� .O lzed Q �y Dee^ hole obse_ Yations made ov. �� Dale _� Desizn Professional Na!>.e: ?.`dress: liE.nat'! lie PUTINNAM COUNTY DEPARTMENT OF HEALTH DMSION- OF ENNVIROINNIENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TR-EATl\/[EN,,T S -\(STEINI Owner: A//5!SC--14 Address: 2-77 ggFj-2, Loc2ted at (street" T M` Section. Biock, Lot Municipality: Watershed:. SOIL PERCOLATION TEST DATA Date of P-e-soakin- Witnessed by: Date of Percolation Test*:1 H o' -o, le N Run n N,-o Time Start — Stop Elapse Time (min.) Depth to I water fro m Crr ound surface (inches.) S,ta rt - S top i Water level drop in inches ' Percolation Rate . '. I min/inch .3 4 2 3 4 .2 4 2 3 1 4 Noces: I T-IZ7-. rn :.,r- Ar fir,,r:i Sheet (, of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLII SERVICES FIELD ACTIVITY REPORT NA Tel: AT)T)RF4R: X77 f/A-/ /—v A)y Street v Town State Zip PERSON IN CHARGE QR TNTFR VTFWFT): Name and Title TYPE OF FACILITY : TNSPFC'TOR f5[`{ f9 TFT Signature and Title RFPQRT RFC'FTVF.D RV: I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. T S FIr ERLITAAMLER. -MD. ,NS, F.AAP "-0Mrr!svone?- ar'Heafth LORETTAMOLINARk. R.N. MSN associate fOMML-STOner of Yeaite' To: I LC) Fax: Phone: f-114 S 7 -1 Re: DEPARTMENT OF H E i -A.L' Tr' Geneva Road. Slr--wszer, New York" i 0509 ROBERT I, BOND[ Counry,E:zcutive ROBERT MORRIS, PE Direcror.'0J- err. dronme'ntai Health From: joserk, S. Pankvlh� or Pages: Date: cc: ,0ndud1,-;C- Cover,, Urgent r Review Please Comment E] Riease Reply E-7. Please Recycie In the eventof transmission /reception difficulties-. Please contact the Environmental flealth.. (EMS) office at (845) 2 "8 -6130. Thank vou. i UL 'Ic" JIT01"'TuMor, ,n ITTIC,162v.3; rbr die e -.9f thc: qc177e-, ;f:hu Mezacc is 91- -)Ll.... 0j, Ise -x, Pus' r LIS �01 ro."!r- 'r 'C MOM : d7u . L . e, !�7 z"01 Ifease in"ne�-ICIM' -q('rM: th(-' or -g! 'C' Y'. •vd. sc Thank vau. Environmental Healt,4 �-8-6 31. rFax 8 2 Water SU00iV Section za,. 114:, Nursing Ham-, Car-.* T 1% Earl- -Incervention/prtschoo! X.: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING (6"45 All information must beLzilly completed prior to any scheduling. Date: 'L° i Engineer or Firm: 6�9,fClfk Phone #: q -!!Z z0 f Person to Contact: L% 9 New Construction Reason: 9 Deeps ❑ Repair Program ❑ Peres ❑ Pump Test ❑ Addition Program Road /Street:�.77� Town: Tax Map #: Subdivision: Lot #: Owner: 0 Project not within NYC Watershed. NYCDEP CRITERLA FOR .TOINT REVIEW AND WITNESSING OF SOIL TESTING YES NO ❑ [� Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner reservoirs. ❑ l� Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. C] Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the. Design Professions 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 tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY ONLY, / gal .�/� DATE: �� TIME: � eo' a�� r Hal l " 4/ /57�c'e COMMENTS: Z Req.for field testAly 4/ 16/2009 LOCATIONS A. B 1 311' 14.5' 2 33' 18' 3 36' 30' 4 41' 35' . 5 47' 41' 6 53' 47' 7 58' 53' 8 66' 50' g 70' 54' 10 73' 59' 11 77 63' 12 .82' .681 13 36' 47' 14 41' 51' 15 46' 551'' 16 52' 501 I ABANDON LOCAL i,nnN-