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PUTNAM COUNTY HEALTH DEPARTMENT
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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
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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:
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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
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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
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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
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