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3.20 -1 -43
BOX .2
■
F 1
66 � IL I
00115
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
MAILING ADDRESS
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER r' PHONE # ',,?V-,6069
ADDRESS z4�'at►dt, Crtt,�>g, A(�f. REGISTRATION /LICENSE # /Coy
Proposal (include e-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 exl:pnt of the repair. „
I, as owner,agree to the conditions stated on this form
SIGNATURE --i,U MM TITLE /j{,c9�(� DATE 1,0
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE r TITLE 19Atr, DATE ,21
(installer)
Proposal approved with the following conditions: J
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. Installer: 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 backfilleO until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Denied ❑
J 7 LIL15
& Title Date Expiration Date
is in compliance with applicable codes Yes ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
PUTNA,M COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
'A Owner: T L;L rv) M LJ
Located at (street): rTS"
Municipality.
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t
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Address: .O �� J -r-✓'�
3.•4v
TM # Section: Blocs: T Lot
Watershed: 6,61— —
SOIL PERCOLATION TEST DATA
Witnessed by: / J 1 col' -
Date of Pre - soaking: c) 7 Date of Percolation Test:
Hole No.
Run No.
Time
Start —
Stop
Elapse
Time
(min.)
Depth to
water from
mound
surface
(inches) .
Start - stop_
Water
level drop
in inches
Percolation
Rate
min /inch
2
d-
a I
5
3
4 I
I
5
1
2
3
4
5
t
I 1
2
3.
4
I
2.
3
I 4
I
I
f
I
�
?votes:
1. Tests to be repeated at same•depth umil approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min /inch, < 2 min for 3'1 -60 min /inch ).
All data to be submitted for review.
_. Deoth measurements to be made .from too of hole.
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SUBJECT TO ANY STATE OF FACTS WHICH AN
'TITLE EXAMINATION MAY DISCLOSE.
IONS SHOWN HERECN, FROM THE STRUCTURES TO
M LINE ARE FOR ASPECIFIC PURPOSE ONLY. THEY
TO BE USED FOR THE ERECTION OF FENCES,
S OR ANY OTHER IMPROVEMENT.
ED ALTERATION OR ADDITION TO A SURVEY MAP
ICFNSED LAND SURVEYORS SEAL IS A VIOLATION
7209, SUBDIVISION 2, OF THE NEW YORK STATE
I-AW&
3 FROM THE ORIGINAL OF THIS SURVEY MARKED
—Al I Rf=
SURVEY OF PROPERTY
SITUATE IN THE
TOWN of PATTERSON
PUTNAM COUNTY
NEW YORK
SCALE: 1"=16'
SURVEYED: AUGUST 12,2006
NOW or FORMERLY LANDS OF HAHN
NOW O'FORMERLY LANDS OF SENNE R r S..t: 1363; Pg. 273
So- 1003; P9. 202 -E yj
a 579*1212OT
35.12' ' 14.54'
565-33'00't
POOR POST F..
OOR POST 1 ;111 FENCE
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AREA= 66 17 sq.ft. 0.15191 Acres
—'SET NE
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ON UNE
12.5'
IRON PIN SET
IRON PIN SET PROP CORNER
O PROP. CORNER
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0 PREMISES ARE DESIGNATED ON THE TAX MAPS FOR THE
TOWN OF PATTERSON
SECTION: 3.20 BLOCK: 1 LOT: 43
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SURVEY OF. PROPERTY
SITUATE IN THE
TOWN.of PATTER,
PUTNAM COUNTY
NEW YORK
SCALE : 1 "= 16'
SURVEYED: AUGUST 12, 2006
NOW or FORMERLY LANDS OF KAHN
NOW or FORMERLY LANDS OF BENNER Book: 1353; Pp. 273
ggg Book: 1003: p0.202
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AREA= 661 7 sq.ft. +/- 0. 15 191 Acres +!- J r5mto '70 L
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SUBJECT TO ANY STATE OF FACTS WHICH AN
TITLE EXAMINATION MAY DISCLOSE.
,IONS SHOWN HEREON, FROM THE STRUCTURES TO
TTY LINE ARE FORA SPECIFIC PURPOSE ONLY. THEY
FENDED TO BE USED FOR THE ERECTION OF FENCES,
:S OR ANY OTHER [IMPROVEMENT.
LED ALTERATION OR ADDITION TO A SURVEY MAP
.ICENSED LAND SURVEYOR'S SEAL IS A VIOLATION
7209, SUBDIVISION 2,.OF THE NEW YORK STATE
LAWS.
S FROM THE OPJG114AL OF THIS SURVEY MARKED
- - -- - ...... —e —ol CWAII RE
12.5'
agin/ 1. °'�• ..
IRON PIN SET
IRON PIN SET ® PROP. CORNER
® PROP. CORNER
• • • • • • • • • • N79° 1 2'20V 49.50'
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EAST
' EAST T
FIRST STREET
(FORMERLY SOUTH STREET)
O PREMISES ARE DESIGNATED ON THE TAX MAPS FOR THE
TOWN OF PATTERSON
SECTION: 3.20 BLOCK:1 LOT: 43.