HomeMy WebLinkAbout4868PUTNAM COUNTY HEALTH DEPARTMENT ® a
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR ✓ I��
YES NO Internal Use Only PERMIT
❑ Iff . Repair Permit issued in last 5 years 13bt in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ET Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION ` •dA�/ TM # 5
OWNER'S NAME `'��,�sk�� �� /� �ncvec{y�c C�y6 PHONE #
MAILING ADDRESS �•,g� A2�p,�y
APPLICANT ,, c
ame & Relationship (i.e., owner, tenant
DATE - zy; --Zo \ FACILITY TYPE PCHD COMPLAINT # N�wr
PROPOSED INSTALLER PHONE #
ADDRESS 2'LoLQ iigs� rt�q ai) 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
I, as owner,agree to the conditions stated on this form
SIGNAT �+ TITLE /'-ja /��� DATE
(owner)
I, the septic install , agree to comply with the conditions of this permit for the septic system repair
SIGNATURE �`? �,y� s � Fir f�r e/6 TITLE G� � � r� 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 backfillpd until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved
nspector's Signature & Title
is in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Proposal Denied
codes
01
1-�- /
Date
Yes
Z
Date
Q No O
Rev. 2/07
ARROW EXCAVATING; INC.
..15 AVALON COURT
HOPEWELL JCT., NY 12533
(845) 227 -4505 (914) 528 -4395
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SHEET NO. a� ��j5 iZn OF
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DATE
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL IIEATLH SERVICES
FIELD ACTIVITY REPORT
ADDRF'4,18I5 /�Pe��sl�i /i fi�o /�o�,r, ! � /`�vf�la� %�«/�•e5/ \
Street Town State Zip
PERSON IN CHARGE
C1R mTFRVTFWFT) %iris G�y�/'ai`F' '�/j'O D te, Z-� l/
Name and Title
TYPE OF FACILITY : S.S�
FINDINGS:
IT�I�PR('T(1R� TFT -
Signature and Title
RFPQRT RFC F.TVFT) BY.,
I acknowledge receipt of this report: SIGNATURE:
02/96
Rev.
Title:
f -Io U S •2
46 WAX k
IT�I�PR('T(1R� TFT -
Signature and Title
RFPQRT RFC F.TVFT) BY.,
I acknowledge receipt of this report: SIGNATURE:
02/96
Rev.
Title:
4
•
PUTNAM COUNTY DEPARTMENT OF HEALTH .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
REQUEST FOR FIELD TESTING
All information must bed completed prior to any scheduling. Date:
Engineer or Firm: .�'L�Utc1 ?cC • v C
Person to Contact: t
❑ New Construction Repair Program
Reason: eeps ❑ Peres ❑ Pump Test
Phone #:
❑ Addition Program
Road /Street: _ f�'� /, 1—S�i�/ 'id,
Town: Tax Map #: ��, '�—• 3
Subdivision: Lot #:
Owner:
❑ Project not within NYC Watershed.
NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTLNG
YES NO
❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner
reservoirs.
Cl 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.
❑ Proposed SSTS design flaw 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 Les 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 USE ONLY
DATE: TIME:
COMMENTS•
Req.for field test:kly 4/16/2009
A
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