HomeMy WebLinkAbout0215DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
4.18 -1 -13
BOX 3
00024
'-�ov
KIM
I�yL
J
1.
. F
•
. I
tl
�I� 9
NO
L 1 �
�
is
1'
1�
■
00024
PUTNAM COUNTY HEALTH DEPARTMENT f
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Internal Use Only PERMrr #
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. K Delegated
❑ `� Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
`? a)L TOWNQqW- trde =' TM# ly, /P -
l �!
SITE LOCATION I & I � T
OWNER'S NAME r inter J PHONE # `?!S `'Z `3 a 46
MAILING ADDRESS S�
APPLICANT
Name & Refgtgnship (i.e., owner, tenant, contractor) %
DATE - j r - ii". FACILITY TYPE j. SS`f PCHD COMPLAINT # +�!
PROPOSED INSTALLER PHONE # O 7ci-- 6%,0 -(J"
ADDRESS REGISTRATION /LICENSE # 1 ®0
Pr_ogosal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed systern)
NOTE: The Department may require submittal of proposal from licensed professional, de nding
nature and extent of the repair.
fib
71)a-
1�tG�- rI7 �►SS�x.�B,ai3t /�e�l� -• itlrt C tz� s �C.��F S�lrc: a
as owner,agree to the con ' ions stated on this form
V SIGNATURE TITLE �'� DATE o
(owner)
I, the septic installer, gree to comply with the conditions of this permit for the septic system repair
SIGNATURE Uci�r t-�� TITLE DATE o°-!- 7-
Qnstaller)
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
Pr sal Appr Proposal Denied ❑
rReoair pector's Ignature & Title Date Expiration Date
proposal is in compliance with applicable codes Yes O No OL
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
-rurlo_
21�r
V7 p Z �
G,- ) �-n -j
-TM *1 14.1 $ -P-
$' 30_ Qr:, jc)
lrl��
/*Ia,v,--),t;.� DeAz"s
Pr 3
pr S-
21f
'low
..................
............
PF
aTrz, if 1�
&('- 2-77q,606
9
PUT-NAUM COTUNTY-DEP-,kRTINIENT OF HEALTH
DIVISION 0117 EN-VIRONMIENTAL HE--kLTH SERVICES
D—ESIU—IN DATA SHEET — SUBSURFACE -SEAVAGE TREATMENT SYSTEM
Owner: 1 in e, 5
Located ar (street):
Municipaiity:
v
Address: 51-1. &--e-
TM # Section: Block Lot
Watershed;
SOIL PER%COLATION TEST DATA
I.
Hole No ...._.._I
.
Witnessed by:
I
Elapse
(Min.)
Date of Pre - soaking: d
Date ot'Percoiation Test:
I.
Hole No ...._.._I
.
Run No.
- -.Run
Time
S tart —
S. top
Elapse
(Min.)
Depth to
water from
o und
Sur face
(inches)
Start - Stol)
Water Percolation
-V r[)
-el-d P
in inches min/inch
2
3
—11
4
2
3
4
2
Mies:
1. Tests to be --meated at same dt-jtb until avoromimate!-Y toua' De-,-.olatior, -iaies are
obtained a, each pe-,coladon .es r hole < 1 Mir; for 1-30 min inch, < = min LOT -0 rnin/incn.f.
.-kil data -.Lc, be submlued for -review,
Depth measurements to be made from t0r of Role.
tea Yt p G P eyq
�'i"� G ft•s o,ev '� � f �3Z 3
SO e-
-?,,v- 'r Co
_r
I10*0 C4*4-OJ crAfr
q"S&P-35
'1 —oZ " zt &;W ti A vg
Alo b0eu,5 -�
6
C
T
ru
ru
CD
0
3
co
0
m
H
Z
n
ao
cn
N
W
N
00
N
0
N
m
lD
N
I.
I
Ak
f
!
TZ
I
I
l
t
e�ll
�
i
p�
♦�
6�� r
j
I
1
(
I
I
I
TPV
I
I
f
I
f
1
I
f
�
i
I
i
i
i
1
i
1
r I
(}g4di
a
■.
�
IT
., Sdc
. all
'91Y!'Yti:
�^•d�.]Qyfi1T
zlyz?q
�
KKK
�t
I
I