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Home My WebLink About0157DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.sc6nyourdocs.com 631 - 589 -8100 4. -1 -11 BOX 2 00157 I. iI 16 olm ISM r 94h 00157 OWNFJ SITE MATT: PERS( DATE PROP( 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 submittal of proposal fran licensed professional engineer or registered architect. Proposal approved Iris-pe6Eor s Signa Proposal Disapproved 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 ccmponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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, po�e agree to the above conditions. SIGNATURE TITLE Q/i°/ . DATE � j /39 TP16: V&te (PCID): Yellow (Tvn SI); Pink (Appliawt) OWNER'S NAME leafbc�, PHONE # %4S %-t* Zob`-E MAILING ADDRESS i z3 3 tit t 3 ►� � t�o�.� er 5� -, Ny t Z 5 l.0 3 APPLICANT Wc,,r ,n S c- ame & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER �� ,.�, �� PHONE ADDRESS tot 2 YLt t�`„ >�� t;5� �.� It REGISTRATION /LICENSE # iy3 i #1'x'7_. t�+� Pr000sal (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. A� &SSO -ol AA „ W,04*W.�/�_�F3 s i',G.4�11 r� t,✓ 1 f)dn ,6Z,11nA1 ivrr r , t,, (- r 1 F rreoL 43 114" / 9i 6 l4°'// �^a � �✓y+ „(�� G Orel gvv S5 75 sLrrs., t � c.,f l�('c �r� a,, L, '"ij iaA &1'Cffi��r5�7%L P(DO -t0 A�X no ;, ffd C-0y ibitic0il6mi . k bjA f6, I, as owner,agree to con diSIGNATURE TITLE_ V DATE i Cwne 1, the septic ins4ler, agr comply ith the conditions of this.permit for the septic system repair SIGNA T�iRE `� TITLE DATE (installer) Pr000sal approved with the following conditions: lt�a.rocurement of any Town Permit, if applicable. ubmission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: Owner's name, Site Street Name, Town and Tar, Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. hstallers' name and phone number 3. Synem 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. C�. Necompleted work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied 4�,� �Zq,(_ c 1 pec-ior`s Signature & Title Repai: proposal is in compliance with applicable. codes COP1:S: PCHD; Owner; Installer PC -R? 9SML Date FW Yes No E) Rev. 2/07 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA.MOLINARI, RN, MSN Associate Commissioner ojHealth DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTING ROBERT J. BONDI County Executive ` . ROBERT MORRIS, PE• •'r Director of Environmental "Health- All information below must be fully completed prior to any scheduling. DATE: ENGINEER OR FIRM: rN Sf��.� U�PHONE #: PERSON TO CONTACT: ❑ NEW CONSTRUCTION XREPAIR PROGRAM ❑ ADDITION PROGRAM REASON: DEEPS.-X PERCS: KIf PUMP TEST: El ROAD /STREET: ax j� %L � TOWN: -F,974f elcso TAX MAP #: SUBDIVISION: OWNT LOT #: YES NO ❑ 1 Proposed SSTS within the drainage basin of West Branch or Boyds Corner & Croton Falls Reservoirs. ❑ C Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ 1 Proposed SSTS within 200 feet, of a watercourse or a DEC wetland. ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered Les to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: TIME: COMMENTS: REQ. FOR FIELD TESTING:KLY Environmental Health (845) 278 -6130 Fax (845)278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 27876014 Fax (845) 278 -6648 PUTNAM COUNTY. DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address Jd33 3 << (a33 Located at (Street) fiovip- 3 It Tax Map Block Lot indicate nearest cross street) Municipality , c.i4.s"s�v� Watershedds . fzc SOIL PERCOLATION TEST DATA Date of Pre - soaking I,--( Date of Percolation Test 6 4`° f NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, _< 2 min for 31 -60 min/inch) �kll.data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 1 ,Po/ - la1 0 � -�°, t7 is R2 7 4 5 2 3 1&1;1--7 // ?,,2-- 2S J �I 4 21 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. s 1 min for 1 -30 min/inch, _< 2 min for 31 -60 min/inch) �kll.data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' i,4.0' . 7 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. �qn 1 i� HOLE NO. HOLE NO. „. h- =: Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered ilk Tk Deep hole observations made by: I-eat Joe Date b(,7-(4 Design Professional Name: Address: Signature: Design Professional's Seal 2 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health I - LORETTA MOLINARI, RN, MSN Associate Commissioner of Health July 15, 2008 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Herring Sanitation Service, Inc. 1072 Route 9, Suite 1 Fishkill, NY 12524 Attn: Jason J. Herring Re: Field Inspection — Zerbo 1233 Route 311 (T) Patterson Dear Mr. Herring: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health A site inspection was made for the above referenced project on July 11, 2008. The following comments must be corrected in the field. 1. Licensee shall conspicuously post license on job site (PCHD Contractor Sticker on Vehicle). 2. All work to be subject to direct supervision of the licensee and licensee must be present at job site at all times. 3. 90° elbows are not permitted. Please use 45° or 22° elbows. In the future with 45° elbows a cleanout must be provided. 4. The gravel provided in the trenches appeared to be very dusty and unwashed. In the future washed gravel must be provided. In you have any further questions, please contact me at (845) 278 -61301 ext. 2157. JSP:kly Very truly yours, Joseph S. Paravati, Jr. Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 �/ '' �- -� U oy�- � � r�c d� � ��n�9 _ � in �� gym ��