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HomeMy WebLinkAbout0124DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.20 -2 -3 BOX 2 00124 �16 00124 I I PUTNAM COUNTY HEALTH DEPARTMENT AI\ /,f11/1• � /1r r-. �� ��r -�/'�. �� �r� �T. � � �r � � T� � P�rP'1� ��/\rP� YES NO Internal Use Only PERMIT # -0 1 ' Z- ❑ Y Repair Permit issued in last 5 years �❑ In Watershed El Repair within Boyd's Comers, W. Branch or Croton Falls Res. L Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME S ocd-A V. TOWN ho' 4c Ir50A TM # 3. ZC) - 2 -_3 PHONE # - 4S k 7X -7,36 % MAILING ADDRESS 1-10 �"� o,t �vU l�g�'i-'�-CT d S c1� i1�`/• 1 `L��� APPLICANT 0 �-J �A C iT Name & Relationship (i.e., owner, tenant, contractor) DATE 1:�� (� Z j 2 FACILITY TYPE PCHD. COMPLAINT # t4 A- PROPOSED INSTALLER °�-(,tav �� S PHONE # _7 ]4% fey S ADDRESS / 1 S j� rr �1.� /?` -,�:� REGISTRATION /LICENSE # W S' 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 repair. I, as owner,agree to the conditions stated on this form 4T*VC SIGNATURE TITLE 6,,vyyV- DATE 3 / /I `f / � � (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE �! - -� TITLE l� (/ , 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 backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ �- 3 Inspector's 81g-nature & Title D to Ekpiratibn Date ,Repair propcsal is in compliance with applicable codes Yes ❑ No .tY COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 N : Toe, 3. 20 -' - 3 3 _a t 1� Sry ,6R , I- hTe- S xive— ��i1�� x,911 Ah Al's cl IT CD t( Sar.T/ Df� 0 fR;T eR Sol = N h .. God• � t° O r z =0 ch LL J -.-# I( —Igll ,R1e- J"C 7-19,vl "We - ,F)(,S; P Ta ,l N —S � Q ner SN — 3!' A To oLT - S.s"' S. It 'Td oOr d A To D$ax - y6' �'• B Ta 19 Ta IJ ro S? a R r,a q8l" io,j- q y' RTdq— 6!` !8 Ta q f}TOS -'r' 1�7—d 7 - U fl -To 7, 0,? - /YTa /d- 66 I 67a !a- So` Sheet _I Of�_ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLII SERVICES FIELD ACTIVITY REPORT NAM -F.: GCt, / /zl�is!/! Tel: Street Town State Zip PERSON IN CHAF.GE Name and Title TYPE OF FACILITY: S STI!> /or FINDINGS: Signature and Title REPORT RFC'.F.TVIFT) BY: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: T) .. / a2 2 a v t4V- -el 1/ -Ax — o��glwa! P si %� k -- Signature and Title REPORT RFC'.F.TVIFT) BY: I acknowledge receipt of this report: SIGNATURE; 02/96 Title: T) .. Py --NAM cc)umTY HEALTH pEPARTMETVT o1VIS14N QF ENVIRONMENTAL HEALTH SERVICES LED L°7 raapalr PalrrlK'anuod in lest r, yaa'a _ u not rn vvrsr errsnsacs O M Repel- within Boyd•. Cwearv. w_ Branch or Caton Falls Plan.' [� Qelegattad E] CJ Repair within 200 ft. ar a wate.aaaarso or 000—ppad watfana Q Joint Rsviaw SITE LOCATION 14 q 13 ow• t TOWN 174 sa^ TM q 3 . Zl'), -- OWNER'S NAME _ ►^: c, PHONE # MAILING AOURESS f=1 el 'laaz)C 330 tTK �1tit• )%1 Ir (2'r✓' G3 APPLICANT _C ...J rl C y' Names Al. 1,401=110nshlp P.O.. ownar, Tenant. DATE 3,f! / I y FACILITY TYPE • PCHU COMPLAINT a PROPOSED INi3TALLER �''T -Ll Gi1r '� �G� CS PHONE I! /� ]f 3' ^DOnESS REGISTRATION /LICENSE a Propose- (Include a separate aicetch locating the house, property lines, all adjaaorlt wella wiihln 200 feet of repair attd the location oT ®xRstlrtg and propose0 system) NOTE: The Mupertmant may require submittal of proposal from Iicensecl protesaionsl ciopanding on the nature and extant of the repair. 1, as awnar,agree to the conditlonstt stntad on thin form / SIONATUFIf_ jR} OL�P 1 +�� L+r..� TTTLE "Y%,c du✓yslV' (owt>er). 1, the septic Installer. agraeo to comply with the eonclitions of this permit for the septic system Mpair SIGNATURE TITLE GATE ( Installer) ProAosal aonrcrveed wlth the following eonam.- 7 . Procurement: of any -rown Permit. it applicable. a. Sutsmiaslon .�f as built repair akatch by tha saptio system installar within SO days of the repair. In duplictod" al 4awvfng; a. Clwnur"s name. Site Street Names, Town and Tax Map number b. L.apaLOn . f installed companonts tied to twa tbaed polnta c. Sy-tam d®scrlption (a.g_. 1.200 Hal. Conorata septic tan K. etc.) CI_ lnstaller5' name ertcl phone number 3. 9yoWm rapa.ir to be parfar 00 In accaraance with the abava proposal anti co"clMono 4_ The proposed SETS repair is oonaldarod a beet fit ttealgn and thBrp is no guarnntna to the rlulrHtlon at which the completed :3ST9 -opal, will tun"on. 5. NO eemplet1ao work Is to be tmc"lied until auttlOeb etion to do so has ocen obtalr+ad fnem the DoeperUTMnt. /lV7'EFifWYL USE ONLY arMDOSaw AppravWo Proposal O@nl� Q (.L1. G -r^• /� _r it 6�IZ �i Z ins c)or`s l netura Ha Title O �� to EScp� on Data Repair proposal is In compliance w1th applicable codas Yes O No j;j— - COPIES: PCHO; C+wner; Installer PC-RP 99ML Rev. 2/07 * * * 30 1 ION XI i n -J S S 300f1 S * * * 996 83MnN 3113 H11V3H 1V1N3WNOSIAN3 3WVN IZ6181Z968 MAnN 131 WdVV:ZO ZIOZ- 9I -SVW 3W11 N0 SUM Z00 : S39Vd 1N3S Wdgt N 9I -d" 3W11 ON3 Wd£q:Z0 9I -80 3W11 laV1S Z00 S39Vd 1N3W 000 SIOL61ZB Ol Wd£t' -Z0 NAM 31VO 996 83MAN 3113 121 Od 321 NO I SS I W S Nb211 A21 OIN 3WV v y PUTNA NI COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONIVIENTA L HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATIMEN7 SYSTEM Owner: Och /101 k Ar) Located at (street): y% S✓7 11Vlunicipality: ec-l". Address: TIM 4 Section: - iyB[ock • ZLot Watershed: SOIL PERCOLATION TEST DATA / / Witnessed by: �f i J 1-� e—� Date of Pre- soaking: 1J /-� -L Date of Percolation Test: Hole No. Run No. Time Start - Stop p Elapse Time fmm'} Depth to water € °und urface (inches) Start - Sto Water level drop to inches Percolation Rate min/inch - I so- /v /3 �2 I. -o L/ l 3 ,, J/0T a.s a -2 r I 4 s I I I 2 I 3 i 4 1 2 3 f I 4 . 3 I � 2 3 4 I s l I I f Notes: 1. T'esrs to be repeared at same depth until approximately equal percolation rates are otttained at each percolation test hole. (i.e., _< t mitt for 1 -30 min/inch, <? min for 31-60 miniinch). AIJ data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97, pe I of t T LJTP�AM COUNTY DEPARTMMNT OF, HEALTH. DIVISION OF ENVIRONM:ENrfAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE LNSPECTION FORM. SECTION A. GENERAL INFORMATION Name of Project . ('T)(V) _� ?�,.�, . County Site Location' Building construction begun ,Extent. ' Is property within NY(- Watershed ? ................. Yes No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. Steep slope : 0 entle slope �iat ' 2. Q Evidence of wetlands Law area subject to flooding ! 0. Bodies of water • Drainage ditches Rock outcrops 3. Property Lines or corners evident .........:.:...... ::............................. es a No 4.. • 'Do water courses exist on or adjoin - the - property? :.....N Yes o 5. Will these affect the design of the sewage system facilities ?..........., Yes 'No 6. Do watershed regulations apply in this development ? :...................... Q Yes [�rTIo .7. Will extensive grading be necessary? ......................... ... .. ...:............... � Yes �No 8: Will extensive fill be necessary. for S STS? ......................................... Yes No' 9. Do filled areas exdst within the SSTS area? .................... ............ ........ Q Yes 1 No If yes, what is. the. condition of the fill? SECTION C. SOIL, OBSERVATIONS 10. Appearance of soil: Sand avel oam Clay Hardpan e . c- c f o 12. Soil borings /excavations observed by -v:>,.tt ��' on / /Z .13. Depth•to groundwater on .14. Depth to mottling on 15. Are test holes representative of primary &reserve areas .....: ..........:.................... es a No 1'6... Soil percolation tests made by' on 5 Ar rL 17. 'Soil percolation. tests witnessed by 1 on SECTION D (on back) Form ST -1 SECTION D. DKAJNAGE. 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes 7�-No 19. Will groundwater or surface drainage require special consideration?.., .................... Yes 20.• Will gullies, ditches, etc., be filled and watercourses be relocated ? .................. t...... F7-yes F " o SECTION E, REM4R . 21. If a common water supply is. proposed; has an- inspection been made of the existing or proposed source and facilities ? ...... ......:...... ..............................: Yes:. E] No . Inspection data _ s 22. Do adjacent wells an"d/or sewage systems exist? ....................... :...:.:.:..................... Yes No 23'. Additional comments " 24. Site observerhxLspector and title 25. Dates) of pbse}rvationWinspection(s) TEST PIT PROLES - Hole r _L_Lot Hole Lot. Hole Lot r r Depth to water ��� Depth to water . Depth to water - Depth to mottling Depth.to mottling Depth to mottling Depth to rocklimp._ Depth to rock/imp. Depth to rock/imp. G.L. D` i � G.I;. • G.L. • • Q.5 .0.5 0.5 1.0 .1.0 2.0 .Y�e. 4`,- 2.0 2'.0 3.0' LV 1 3.0 3,0 . 4.0 4.0 4.0 5.0 6 5.0 5.0 • 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9:0 9.0 10.0 10.0 10.0 H SITE LOCATION PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES e PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAI I ' i 40/, O Internal Use Only. PERMIT.# "a -0 1 - r 2 Repair Permit issued in last 5 years Q Not in Watershed ❑ 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 OWNER'S NAME MAILING ADDRESS 49 So(C4 St. TOWN ha- 4rsOA TM # 3 : ZrJ —.2-3 NE #24S k0Ss`7367 APPLICANT _ O vJ yl C r Name & Relationship (i.e., owner; tenant, co tractor) DATE �►`j 12 FACILITY TYPE PCHD COMPLAINT # PROPOSED. INSTALLER S 4-L4 r + &c PHONE # ADDRESS 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 nature and extent of the repair. I, as owner,agree to the conditions stated on this form / SIGNATURE r TOoa TITLE t -C 0 �c/1�Ir DATE 3/1 (owner). I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE 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., 1.250 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 ❑ _ 3 Inspe ors Tignature & Title to Ekpiritibn Date ,Repair proposal is in compliance with applicable codes Yes ❑ No Ll--' COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 FROM PHONE NO. : Jan. 06 2011 10:49AM PI n L;y of Cli DIVI'sion of ao, not'od for rutria-m co-!"u-it-y al CIO- a, Wei A/W& loe-IR113#1Y FOR -s-fA'ee 7- J-06 fig;m-"' Gd9d Ce- DR-rue. DdZ,rve Eh',-S;ri'-svoL i0oo 6,411 14/zo 1600 6t:) 'z>f — (Dg A 0 1 -0 �- P.sq TA f, p-