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00155
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PUTNAM. COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
M
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
Internal Use Only PERMIT-#
Repair Permit issued in last 5 years ❑ blot 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
TOWN QSSV\ TM # 13,--,2-
PHONE # -it1%- axbcl'Z:�,
Name & Relationship (i.e.,
DATE ;�_ Via_ �p FACILITY TYPE�0. PCHD COMPLAINT #
PROPOSED INSTALLER s �4w.`v�_ . PHONE # 11Z��-
ADDRESS k 1��"`CO K�Mli� sla a REGISTRATION /LICENSE # 1055
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.
1, as owner,agree to the conditions stated on this form
SIGNATURE/ O TITLE
DATE
(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., 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 posal Approved Proposal Denied ❑
Inspector's igrfatu Fe &Title ��t� Date Expiration Date
Repair proposal is in compliance with applicable codes Yes 11 No
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
Street
Sheet r of�_
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLII SERVICES
FIELD ACTIVITY REPORT
111111111il I!,
Town
State
Zip
PERSON IN CHARGE
nR TNTRRVTFWFII: t v;,a natP x3 /v
Name and Title
TYPE OF FACILITY : �I hQ 1� (�� �Cs�` Svc f
FINDINGS:---a /9-3
r i t ®,n r� }�ie �i ,ten � r V S 1 l�—! `vc 'y #1 5s M QJ/
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Signature and Title
I acknowledge receipt of this report: SIGNATURE;
02/96 Title;
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As built drawing
A = house to house trap = 1'
B= house to Septic tank = 25'
NOT TO SCALE
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D
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W
A
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Raymond Libero
70 Baldwin Road
Patterson NY 12563
NOT TO SCALE
-H6 LL se Trap
NOT TO SCALE
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A = house to house trap = V
B = house to Septic tank = 25'
C = repair to house = 25'
D = driveway to repair = 34'
NOT TO SCALE -
D
R
I
V
E
W
A
Y
Raymond Libero
?Q Baldwin Road
Patterson NY 12563
AS- BUILT -DRS VIANG
PERMIT #R - 023 -10
TM #13. -2- 48
NOT TO SCALE
House Trap
�G�7iovi vI,
NOT TO SCALE
above described will-be constructed ae;shown on,the�approved ameni ' ent there to and in accordance with the standards, rules and regulations ' p -t a -u nam
••.
County s-Department of :'Health,;:and that ;on completion thereof a Certificate of Construction Compliance' `satisfactory to the Commissioner of Healthwill
Lie; submitted to -the' Department; a' d-"' :guarantee'w�IRbeJturnished the' owner his successors .heirs.or assigvjs'by . the builder, that said buJder' will;
.
-`, .place in good -,.operating condition any oartr of said sewage disposal - system during the:pe6bd of two (2) years immediatgly following_ the date of the issu-
ance of -the approval of ;the - Certificate Construction, Compliance of the original systein- any repairs thereto 2j:;ahat;Ehe. drilled: well described- -above
•: -
' Will b - located as shown on=the approved,plah and tFiat said well,willbe installed i `accordance`w�th.,the ,stars vales and aregulations of ?fhe • Putnam '
County Department of Health
Date- r ( 5�9ned �- ~ P.E.
R A
Address, �'` - License No
APPROVED-FOR CONSTRUCTION This;approJal expires o' ne y the date issued unless construction' of the building has, been undertaken-. and' is
revocable for cause or may. be amended ory`mod�fietl "when conside ' ecessary by the COmmissio er rof Health Any:- change: or alterat -ion .of construction,,.
require ;a ew; ermit. .Approved for disposal of.,domestic ry sewage, .a iivatd er supply only
r
Tale
Date
-s
PUTNAM COUNTY DEPARTMEN OF HEALTH
r
-
.^ Division of; Environmental Health S* Services Carmel, N Y 10512
CONSTRUCTION.-PERMIT FOIE SEWAGE DISPOSAL SYSTEM' . �" �.o'04
Town or - -Vi age
h
Located . at �!!!1� Section
Block
Subdrvisioo -,"Lot-' �
Job
-
Owner '.• Address��/lll�is�s1•G�
Building Typed Lot
s
µ 13c
Number "..of Bedrooms "^-� ` Totat Habitatile'"Space
Square Feet'
Separate 'Sewerage System to cgnsist of�s� Gal Septic Tank " ..�-. rsimeal feet X
Width trench'; .
- To; be constructed by G- Address
Water Supply Public Supply From
`:Private- Supply to be drilled by A
C
•
Address
-
� �C- SiL
Other Requirements f0 = +
i "represent th'at'I'am-, wholly and completely' responsible for the design and location of 'the 'proposed system(s); -1) that, he
separate sewage •disposal
Sys em'
above described will-be constructed ae;shown on,the�approved ameni ' ent there to and in accordance with the standards, rules and regulations ' p -t a -u nam
••.
County s-Department of :'Health,;:and that ;on completion thereof a Certificate of Construction Compliance' `satisfactory to the Commissioner of Healthwill
Lie; submitted to -the' Department; a' d-"' :guarantee'w�IRbeJturnished the' owner his successors .heirs.or assigvjs'by . the builder, that said buJder' will;
.
-`, .place in good -,.operating condition any oartr of said sewage disposal - system during the:pe6bd of two (2) years immediatgly following_ the date of the issu-
ance of -the approval of ;the - Certificate Construction, Compliance of the original systein- any repairs thereto 2j:;ahat;Ehe. drilled: well described- -above
•: -
' Will b - located as shown on=the approved,plah and tFiat said well,willbe installed i `accordance`w�th.,the ,stars vales and aregulations of ?fhe • Putnam '
County Department of Health
Date- r ( 5�9ned �- ~ P.E.
R A
Address, �'` - License No
APPROVED-FOR CONSTRUCTION This;approJal expires o' ne y the date issued unless construction' of the building has, been undertaken-. and' is
revocable for cause or may. be amended ory`mod�fietl "when conside ' ecessary by the COmmissio er rof Health Any:- change: or alterat -ion .of construction,,.
require ;a ew; ermit. .Approved for disposal of.,domestic ry sewage, .a iivatd er supply only
r
Tale
Date
-s
Gentlemen:
This letter is to authorize �,�}, ZY,
a duly licensed professional engineer or registered architect
(Indicate)
to apply for a Construction Permit for a separate sewerage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulgated by the Commissioner of the Putnam County
Department of Health, and to sign all.necessary papers on my behalf in.
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article.:145 or,
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Counters'gned:-
r�ss
Very truly--y-gurs,
Signed
r P1 e ty
Address fo�9
is
4M R . A . ,
G � 4
No.
Ad resS 292 - �,�OfTHE
Telephone
9i- 229= 6,96�-
Telephone.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH,SERVICES
DESIGN DATA SHEET - SEPARATE SEWAGE.. DISPOSAL SYSTEM FILE NO.
Address c� �,�, ,
��-
Located at (Street), p ,�� .;
Lot
(Indicate nearest: cross 'street)
�`--.-
Municipality f�t�F�,,;��r Watershedh
SOIL.PERCOLATION TEST DATA REQUIRED TO BE. SUBMITTED WITH.APPLICATION
Hole
Number CLOCK TIME PERCOLATION
PERCOLATION
+1
Run Elapse Depth to Water. Water Level
#.
No. Time From Ground Surface in Inches
Soil' Rate
Start Stop Min. Start Stop.,. Drop in
Min/in.drop
Inches Inches Inches
l ors - 33 /
3
4 '\
5
i 1.e7 ?/o 1v6,1
a
3 /d S?"' L f8 f
4
5,
�1
2
3
4
5
Notes: '
1) Tests to be repeated at same depth until approximately equal soil rates are ob.-
tained at each.percolation test hole. All data to be submitted for review.
2) Depth measurements to be made from top -of hole.
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TEST-PIT DATA REQUIRED 20 BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE No.
G.L..
6"
12"
18
24'
3 0'
3611
48
5411
6 0"
66"
7211
78
8 4"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY EL 4 f 6 Date 0
DESIGN
Soil Rate Used —6/0 Min/1" Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity 146,o -Gals. Type__ 1tj:yj,tz
Absorption Area Provided By_=L.F,.x24" 361' —w-id_ th trench. Other
Name.." -5 Si=
Address
PUTNAM COUNTY DEPARTMENT OF. HEALTH
'PIT
Soil Rate Approved Sq. Ft. /Gal.
FH
f
NO 2920,�
'Date
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