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PUTNAM COUNTY HEALTH DEPARTMENT a
l% DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Internal Use Oniv PERMIT# K- 1 -t"L-
LJ .4A Repair Permit issued in Iast'5 years LJ in Watershed
Q 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
SITE LOCATION q 3 TOWN ,(0 1 TM # Lj
01 -- i q___1 -
OWNER'S NAME �,r,�� ,�,���,��,� �� HONE # /d U
MAILING ADDRESS
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT # N
PROPOSED INSTALLER
.6"Y
PHONE #
-000
ADDRESS j i'
or,• /�Jw�.�
r REGISTRATION /LICENSE #
ri'l ti - 5, - 09 y o
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. 300►
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE DATE
(owner)
I, the septic installer, agree to comply w' h thpconditions of this permit for the septic system repair
SIGNATURE TITLE d f DATE 4-12-.,10
(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 backfilad until authorization to do so has been obtained from the Department.
Insdector's SIi'anature & Title
is in
INTERNAL USE ONLY
Proposal Denied
- / /: �'f
with applicable codes
a
Date
Yes ❑
M
COPIES::,. Owner; Installer
PC -RP 99ML Rev. 2/07
PUTNAIM COUNTY DEPARTIN, NT OF HE-ALTH
DIVISION OF ENVIRON1 IETNT-4L. HEALTH SERVICES
DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner* Addres s:
L1,3 TIM # Se M.
Located at (streetl: ction: Blocky Lot
Municipality: ''Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre-soaking: Date of Percolation Test:
Hole No.
.
T1 1m e
S
Run No. - Start t. ar — - -
Stop
Elapse
TJime,.
(Min.)
Depth to
water ter from
. . - -ground .
surfac
e
(inches)
Start - Stoo
Water Percolation
Rate .
level drop -
in inches min/inch
00
2 1201
3
4
I.
5
2
3
4
5
J
2
3
4
3
4
Notes:
1. Tests to be Teoeated at same death until ar)rro-MmaieIN eaual -oercolation rates are
obtained a! each percolation Lesi hole. (i.a.. < 1 min for 1-30 miniinch, < = min fOT -.5"; min; inch j.
-,kil data to be submitted for review.
Depth measurements to be made from ton of Hole.
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Fax.- 845-878-9222 Residential & Commercial Putnam County Lic. OPC2818A
Putnam Septic Lic. 01034
Phone: 845-878-0001 124 State Route 22, Pawling, NY 12564 west. county Lic. *wr,199a7.Ho7
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
(DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY.REPORT
I acknowtedge'feceipt. of this report: SIGNATURE;
Q2/96 Title:
i
I acknowtedge'feceipt. of this report: SIGNATURE;
Q2/96 Title: