HomeMy WebLinkAbout0111DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
3.20 -1 -26
BOX 2
00111
me
�I
Is r
�Id
■ ■
''
I,
+TT
IN 7''
"I
r
:r
61
00111
a
SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES D' D
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR / J� X
40f Internal Use Only PERMIT* 77AA
Q! Repair Permit issued in last 5 years ❑ ot in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. elegated
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
OWNER'S NAME
MAILING ADDRESS
APPLICANT
- 30e' -, i4a�i .6�y TOWN TM 4
PHONE #
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE /Ci =.t� PCHD COMPLAINT #
PROPOSED 114STALLER / ✓�?n.Cu% �,�� PHONE # l ('F y -Cti�
ADD RESS
.2 Q)
r�r REGISTRATION /LICENSE # is 5�
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 the renair- Cawere- 0'
I, as owner,agree to the conditions stated on this form
SIGNATURE _ TITLE DATE
(owner)
I, the septic installer, agree to corn ith the conditions of this permit for the septic system repair
SIGNATU ) TITLE .c DATE --4Z �
( installe
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 Rr Proposal Denied ❑
s ector's Signature & Title Dafe Expi ation Wate
Repair proposal is in compliance with applicable codes Yes Q No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
6/22/11
Septic Repair, R- 099 -11
16 Orchard Dr. Patterson NY
I inspected a repair at 9:00 am in Patterson at the above address.
It-appeared to be installed as per drawing by Amaxx Construction.
I call Jason from Amaxx at 10:15 telling him he can backfill.
Pictures attached
Cris DellaHpa, CCM,PMP .
Projects Coordinator, Putnam County Health Dept
.6 t
-.mot
-
ME,
sw
I IN
:t,,._ _sue #�
OAI
�IJ
mmmmmmmmmmmm
■■■■■■■■■■■■■■■■■■■■■■■
�
1
PUTI -M COL -INTY DEPARTMENT OF HEALTH
DIVISION OF ENT-VIRO-N-l"MENT-Al HEALTH SERVICES
DESIC N- DATA SHEET= SUBSURFACE Srw4
OE TREAT1VfE',,N-T S Y. STE-,,\,[
WPM
Located at (street":
Address: A� 07-�-e-V-b 57-
-3,,2-C7 - I - a-co
TM -" Section: siock, Lot
Watershed:. i5A -91
- R-AAle-4
SOIL PERCOLATION TEST DATA
Witnessed by:
.Date of Pre-5oal:in;,, Date of Percolation Test: 6 Z1311,1
I
Hole No.
Run No.
i
Time
Start —
Stop
i
Elapse
Time
(min.)
I Depth to
I water fr6m a.round
surface
(inches)
Start - Stop
Water
level drop
in inches
Percolation
Rate
min/inch
30
13,3
2
3o
-0 2- I
;L
15-
.3
.5
(-
!
2
3
4
2
4
2
4
Notes:
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED FINTEST HOLES
j HOLE 4 HOLE HOLE 1 HCL-
0.
e- SaJ
2.7
2
4.C'
4. 5, V/
7.0'
10.0,
Lidicate level at w1lich a—roundwaier, is z:i
cour.t,r-
Lidicab-, level at which mottling is observed &JON4
1--ndica,re I.ev--t to w�llclri water level rises e,.-- beinq e—Licountered
De2p hole obsenvarions made by: Date
Desilc--M Professional Na,—,i--
Address:
1-3
{ z�APUA=
At X.
'.h
LY' ' •l -
/''�`�
',�- rF'i %.`[ "c - { -. - ___ - . }' �: f •c _y `.. ,. �`i- •:' >.v: - ..S n t: -' -Y•' 1.. ^-' _! �: {:i �..'^[ : 4
- � w
•-r- : �y%�. � `,..pct_
-r.
- '':1Y•- - - _ _J'•' - - :_Y 4:'- S ^ -7. � cS- �-: Z.. �- �.>- J- _'- ,:'•r•N,it.: " :t�i+ +- .SS ^:,y �r.J� �
-
. .'r
...
_ - j � :rho - t .�.•' ..iL ice.
eel
s
•F - -S
�icir•R. .._ _. -- - -3.. ._.._._.
f- fir`- �i-Y• -- _ _ —i_ -_- .1 i._-a. . . -
_ -. ,> -
�.: _ ^a- _ � .. -.`C- �.5+ ^ ^.':�'. .tic. _ - -_ -.. .z-- .:S�i:r- i:- :- 'st•�1• -� ...: '. , -... ...�... -_ -�. .Zi�� ->_;. -. .., -irk
��w�J. ..1 •. S= 'S'.:C {%<:I:S' -. ;, ,. J::. n; ,.; -s, -� :,'..z '�)f � ""`z.. \.
-
- .eta. -"i': t: -..i .try: e. -. :... - '.S >.4x..' :�.<;. -: y +t:': -: �-` \: i.w'i �.:ri,!•.e�`_ -`. r''y..';:�..
_ - j � :rho - t .�.•' ..iL ice.
eel
s
•F - -S
�.: _ ^a- _ � .. -.`C- �.5+ ^ ^.':�'. .tic. _ - -_ -.. .z-- .:S�i:r- i:- :- 'st•�1• -� ...: '. , -... ...�... -_ -�. .Zi�� ->_;. -. .., -irk
��w�J. ..1 •. S= 'S'.:C {%<:I:S' -. ;, ,. J::. n; ,.; -s, -� :,'..z '�)f � ""`z.. \.
-
- .eta. -"i': t: -..i .try: e. -. :... - '.S >.4x..' :�.<;. -: y +t:': -: �-` \: i.w'i �.:ri,!•.e�`_ -`. r''y..';:�..
08/21/2011 00:38
FAX 8450789222
f6R(
AMAXX CAMEON
HEALTH DEPARTMENT
946NMENTAL HEALTH SERVICES
1&002/002
TM 0
• W(A T TOWN
rs
PHONE 1i Y)fj
NAME . . . . . .
"12
'AN NM ADDRESS id-Az
LicAwr
LrtY TYPE r. pCHD COMPLAINT #
PHONE& F-�T d jC
osm
*:
Clo INV
REGISTRATION /LICENSE IV
4
P 6
Wss.
one, all adjumN wdW wfflMn
houm, propY
ripeir end fl!eee :' tu=RmmAp- F-
MW of proposal frm limrsed pmdewAwW depeMno on tw
The "dire
iifiio ww Were at
12
-for .0
I. �--�deam
'm to fift*=
A
DATE
I wj"Aq TI TLE
ns
o of thb permft for ft septic SYSISm repair
.7/
14MATU
TITLE DATE
Fe
of
:goft gVam kwWW vollhin 30 dVA of Vs MPfk. In dupkab dWwbW
aw TOX Map MMb*r
room. 1*0
qoo�ww 60 points
b. Uicallm Of
IL 800m MOO
obwa popomw aw omdtk=
i*lt. spaml� repir widd
io tw durm*m
bW fit 601F EW Omm 19 fm) PAW"s
is do so hm been obtained from the DWSMOL
Use ONLY
Dented 0
Aoproyed X 0 .m p. W
-6-#Wm DW
My r
No 0
Is
', x - WMES.
Rev. Z107
W-09ML
f
Fle
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH'�-
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
Anng-pFCR: 16 ST S ®ZSOA%
Street Town State Zip
PERSON IN CHARGE
Name and Title `
TYPE OF FACILITY
FINDINGS: Fd. P
Signature and Title
REPORT RF('FTVFT? RV:
I acknowledge receipt of this report: SIGNATURE: —
02/96 Title;
n —
r
v
ZV'
s•�3
Signature and Title
REPORT RF('FTVFT? RV:
I acknowledge receipt of this report: SIGNATURE: —
02/96 Title;
n —
IRI-91"LYl,1 tYiYLAM fRUhrCRY!RUM iAL rY_'ALIh V44
• �... ..;,:.l•`' ,t -� fir %4,t`:"};.' • �7�: i;
. .. .. •fray • J�i1q'' •
• " '• \gin ` Ali
PUTNAV, COUNTY HEALTH DEPAFTM t'?'
DIVISION CF ENVIRONMENTAL
THIS IS NOT RED 1
#'
PROPOIAL FOR EXPLO-AATiON OF SEP'T&SYSTF -M F1
All information below must be 1gilly completed prior to:A�: ��i�.r.�A.��.p��•;E .' '= ; "c��.�;�� '
SITE LOCATION X-1,40l TdWNAF.'
•' JS 47 tt, •`
OWNER'S NAM 7_�NAME
MAILING ADDRESS
^,.1
�i1'LR�n+�rr:..i . -� — !�,F!'C,�• r� —.r.. — •`n �f:.: =' F •• ,
PROPOSEQ CONT1R' ACTOR /INSTAi! chi
ADDRESS REGISTRATC3%YI�ICA •:':' x �` ,,'.
MjWn for ex lormlan:
lure to surfstJe CJ baewtjp ir; house 0 find limits of system-fort jvpwr.G 4iixpisirl below]
G X.4 A I
�77 Xh U
Fg3 Q0UNjy1jSg d.ML,
r f [
.T am• _ : }, •.•. f,, t..f ��•ri �l .
�j� //.- ! I /fy //p ' •: y'y -f,�lA•.p.:' ,fit '
k A� (/` • '!• \(' �,. ., 'n,. I.•J. yin :4.oY' 5f 1: �•'S \. ;1�, •:
.\a:rk'Iry�rr f.'rr '
Insp clots Signawre & Tide Date
Appoimtmont Date! !D
. •N,, .' I.1 Alrv3',
Zoo /loop NO3WVO XXVWV ZZZ88189V8 XVA OL:LO LL07/90/90
DANBY
LA
s
0
L,
<
z 2
tol
GAR ern CHA
Z 311
71 R 0
Little Red M Pat erson
_—Schucil I luu 0 z Sta
0
FIR.
0
NP NO
0
AR LE QUARRY
k
ES
C) The
Irl
J.
Great
64
Swamp
- rl 2500 6 3
Mo
le.
PO
J
Z)
CO
I
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME _ FRFn PITT TFR PHONE
SITE LOCATION P.O. BOX 114 PATTERSON, N.Y. .
878 -6485
MAILING ADDRESS ORCHARD STREET PATTERSON, N.Y.
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DALT TYPE FACILITY RESIDENCE
PROPOSED INSTALLER BOTTGE SEPTIC , I NC PHONE
279 -6069
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 fran licensed professional engineer or
registered architect.
Q 4 6--i e w azzmc' i
>')2�� • ill2•,'1 -r�i ;fit: C ; t`I'Z c "•� i' .� i'('� ?�2�i -�i r y y7?!• .��'. ?:✓fit' ��2cxf��.5'c":�i S'�(S'2'�.
,7, } /'�if�� , � /}r' �_ c??<) �i �t= f'r -W szl[h2 Ald -- Ar e-9,1GZ7 )aY SS
Proposal approved Proposal Disapproved
6
Inspector's Signet & Titl
Proposal approved 'with 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 ecmponents tied to two fixed points (e.g.,house corners).
d. Systen.desc.ription (e.g., 1250 gal., concrete septic tank, three precast 6' diam. x 6' deep
drywel.ls 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, or reported agent of owner agree to the above conditions.
SIGNATURE iii, _' y TITLE DATE
TPM: Rhine (MD); Yellow (Tan SI)• Pink (Aniiamt)
Z-i
Jc? L L -"
FRED PULVER
ORCHARD ST.
PATTERSON, N.Y.
R- 158 -92
Installed By:
/3-..,
O
L� /'�J' ox
BOTTGE SEPTIC, INC.
SODOM RD.
BREWSTER, N.Y. 10509
JuAe 9, 1992
'lye
!rS b
. . .. . .. .. ..........
a
6jm,t,
.............
/ /�SOA