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HomeMy WebLinkAbout0110DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.20 -1 -21 BOX 2 00110 ;. Ir I' .. 00110 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR _7) YES NO/ Internal Use Only PERMIT,# Q d64i� I , ❑ f/ pair Permit issued in last 5 years Li �D4ot in Watershed ❑ 1. 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 5 f `� I-Dq 5 e. TOWN &T�et3b9' TM # 3,2,0-1 Z/ OWNER'S NAME Porf,'l(p -Ee ,�-,a 066o.rJ 61 PHONE# MAILING ADDRESS 19, ie;X t APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE �'j FACILITY TYPE Y 1�, �-t PCHD COMPLAINT # LI PROPOSED INSTALLER foe 14 . � We PHONE # ADDRESS j p/2o woe, &,4 C /� �G�I TRATION /LICENSE # -/ 6 7 Q Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair sand the location of existing and proposed system) I, as owner,agree to the condit70; ated on this form �j-�tf 11(2 TITLE 0 (NM DATE " SIGNATURE „(� ���� -f %� (owner) I, the septic installer agree to comply with the conditions of this permit for the septic system repair TKCI SIGNATURE + TITLE i yvY DATE 2 (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.) A. 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 ❑ 13 Inspector's Signature & Title Date / ipfitio Date ,Repair proposal is in compliance with applicable codes _ Yes l� No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 46A, Ilk I joC� 9 CO Vi H iv Putnam County Department of Health Division of Environmental Health Services SS Date: Street Location: Town: TS Repair - Final Site Inspe ion . Inspected by: e5;�, Instal Owner: Repair Permit #: ,� -ooh - / 3 TM # Install %i97'I"' L�yr %�tPs `30, Z / - 2/ 1. Type of System: Conventional 0 Alternate 0 Comments: 2. Se tic Tank Yes No N/A Comments a. Septic tank size -1,000 ... 1,250 ... other ..... 7i5J ZIC b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. . Distribution Box i, All outlets at same elevation (water tested) ... ii. Protected below frost ......... . ................... iii. Minimum 2 ft. Original soil between box & trenches e. Junction Boa - ro erl set ........................ .... f. Trenches i. S stem completely completcly opened for inspection ii. Length required 410 Length installed VD iii. 'Pipe slo a checked ... ............................... iv. Installed according to plan ..............:...... v. 10 ft. from property line - 20 ft - foundations ... Vi. Size of gravel 3/< - 1 '/2 " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... viii. Ends capped .... ............................... = . Pump or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per a roved plans 66- b. Fill section - c. Distance from water course /wetlands 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. All pipers flush with inside of box ......................... c. Back-fill 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 ............................ brass awn rue _ Additional Comments: RFSI Rev- 011312 c PUTNA COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIG[v DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: —�eA00 Address: % OCC --kIl S-L, s Located at (street): TM # Section: —Block— Lot Municipality: �a r�f�mM_ Watershed: �a s 4 ara_ " SOIL PERCOLATION TEST DATA Witnessed by: 1 l Date of Pre - soaking: :3 A//3 Date of Percolation Test: -3 S/ 3 Hole No. Run No. Time Start – Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stto Water. level drop in inches Percolation Rate min /inch ,✓ 2 J �� :sol cc rs� od k4 caPa� 3 v 4 5 a. 1 /o: s 4 5 1 2 3 4 5 1 2 3 4 5 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. I/ �/ �'r, 70 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OHNER O S NAME .T d jtie,z2z- �r �.� 4.a / S PHONE SITE IDCATION q ©(2G r j&O 27- y�r : � j /V ��_ TO 12. NAIDMI11W, x'79 -3( 71 PERSON INTERVIEWED PCHD Caaplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE ' ;? TYPE FACIISTY PROPOSED INST e b is ' PHONE L i'D Pro (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require suhnittal of proposal from licensed professional engineer or registered architect. _ ,WELL 5 /f-, -�? ,z5t x , `sue, `- .5 SZa Proposal approved : Proposal Disapproved Inspector's Signature Title roDosal aonroved -frith the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch.in duplicate showing: a. owner's name:. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e Installer's name and number. (e.g.,house corners). three precast 6' diem. x 6' deep 3. System repair t:o be performed in accordance with the above proposal and conditions. I, as owner, Uore; rted agent f er agree to the above conditions. SIGNATURE TITLE DATE EP EM: Vt ite (PQHD): Ye]Lk w (fin ED; Pink (Afpl. amt) PUTNAM COUNTY HEALTH DEPARTMENT Awl �VL DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE "TREATMENT SYSTEM REPAIR F. SITE LOCATION Internal Use V pair Permit issued in last 5 years pair within Boyd's Comers, W. Branch or Croton Falls Res. pair within 200 ft. of a watercourse or DEC - mapped wetland 5 Ii toU -Se.. OWNER'S NAME Po r LJ t o • Ed - I .d MAILING ADDRESS . A Z913,g c 1 4 -� TOWN / lJu.,# -.ev5 o, PERMIT i W-6,, i �5 41 z� ❑ ,POot in Watershed (]' Delegated 11 Joint Review TM # PHONE # APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE _ :J 1'5 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER �' /�, .c. bly , r .! _PHONE #. %y 75 ADDRESS 01I a `,,,AC /�I 6 TRATION /LICENSE # ,/ 1-6 I � 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 ubmittal of proposal from licensed professional depending on the nature and e�tent oft a repair. S� e.402 I, as owner,agree to the condition stated on this form SIGNATURE li f('I TITLE C W117 DATE (owner) I, the septic installer agree to comply with the conditions of this permit for the septic system repair SIGNATURE _ CL 1/�ti'K, TITLE yY DATE 2 6 (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 backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Q Proposal Denied ❑ Inspector's Signature & Title Date Expipfitio ate Repair proposal is in compliance with applicable codes Yes H No D COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ore-hard S+I. �2- 0 (o v Fev- 1,0 Cku, v d, r � low 0 ve F'77' Ctr F'77' PUi'NAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR 0WNERIS NAME J i.5(i%� 7- d1JJ/Vgr -, Z l�rS t SITE LOCATION q G (2C a S > - -- -- :kl, 11% MAILING ADDRESS PHONE 71$ o'79 -36 71 PCHD Complaint ## Name & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY - - Pea PHONE Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. ii E LL L� L -L& t C & W I -7 Proposal approved w/�� Proposal Disapproved Inspector's Signature-C Title pate Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Sutmisgion of as built repair sketch in duplicate showing: a. Owner's name:. b. Site Street Name, Town and Tax Map number. c. vocation of installed canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, o rel rted a t f er agree to the above conditions. SEC" SIGIN,ZURE � TITLE �" DATE � A2— IPM: Vi&te (PAD): %Ujow (Taro ED; Pink (Appticent) y - - r \ } 1 DANBY LA 1 � --° 292 63 Z A k 1� �p I S DR elm ,AKA 311 1 est ; ittle Re 0 hersoR l o K}Np5 . .+ f,�....� � z a NO t O Y p G Hl4 Nv m S,� 1 i AR LE OUARRV - p Es 4 VIO A f G 0 The Op . ti Great 64' r� -s ^'rte z- � s�,ba �` � •�} 3 Z iUU �•�� yy�����Ky ������:� a 311 � ,�� Swamp $} ti 1256;j .......................... ............... cZ QO C +Lkyz �£�• was '` 93 xb s. p t 3 Maw ,� 3 O J Cem , z tuft?i N j m DEVbN COUC O ,9 H k 164 osy,Rf C C Z lT 0 V J I � �� ¢� y ' IMendel Pond