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PUTNAM COUNTY HEALTH DEPARTMENT S-°3 ?(a. 01110
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CJ a
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES 0 Internal Use Only PERMIT # -
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. j Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION / ate. Prc,4-o,. FA TOWN 'P"NdL TM # 7/1
OWNER'S NAME MF- kA%85 I PHONE # 91/!57 Q Y' ; ffVy
MAILING ADDRESS PEW ia 1, 11 (85-
APPLICANT.
p, Na e & Relationship (i.e., owner, tenant, contractor)
DATE / yti F CILITY TYPE 62CIf PCHD COMPLAINT #
i,Y 1r7 7 Ir—e- / ( .
PROPOSED INSTALLER 2(/ G PHONE #,q 4S'g- a.6
ADDRESS :j2u r -Pt4js, If A L L Ft)S 23 REGISTRATION /LICENSE # 11DY3
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,agre a con itions stated on this form
SIGNATURE TITLE '2, 9 DATE Z
(owner)
I, the septic inst Iler, agree to comply with the conditions of this permit fo the septic system repair
SIGNATURE TIT E 2,2- DATE
(installer)
V I VWV001 aNNi vvcu wun a is wuvvrn iy W1IUM 11 10.
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 Dat6 Expi tion D to
Repair proposal is in compliance with applicable codes Yes ❑ No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
TESTTIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
Indicate level at which groundwater is encountered /o
Indicate level at which mottling -is observedo��.
Indicate level to which. water level rises after being encountered
Deep hole observations. made by: �� . G r-l_� -Date
Design Professional Name:
Address:
Signature:
Design Professional = Seal
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET —'SUBSURFACE. SEWAGE TREATMENT SYSTEM
Owner: J� �/4S j-� Address: /,I- 7,7,Oofp
Located at (street): TM # Sections` Block .Lot 1
Municipality: Watershed:. /Vup4aq `
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre - soaking: Date of Percolation Test:
Depth to
water from
Time Elapse Water Percolation
-
Bole Rio. Run No. Start — Time ground level drop Rate.
Stop (min) surface in inches min /inch
(inches)
Start - Stob
Notes:
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min /inch, < 2 min for 31 -60 min /inch).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Form nn -97 no I
1
2
5
-
1
,
2
3
4
s
1
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I
2
3
4
1
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2.
3"
Notes:
1. Tests to be repeated at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min /inch, < 2 min for 31 -60 min /inch).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Form nn -97 no I
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