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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
l r2
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR) si
YES NO:/ Internal Use Only PERMIT #
❑ 21 Repair Permit issued in last 5 years ❑ Not in Watershed
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair wit W2 200 ft. .91 a to u or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 35 3 i W TM # 1134 —j-q,3
OWNER'S NAME 4fkrV5 L, ,*iy A i4lyJC PHONE # ql "ff -Q�13Z-
MAILING ADDRESS ,o '45 0444 f
APPLICANT �� �' ,, �'� G
Name & Relationship (i.e., owrSer, tenantce6ntmc 2kL-_,
DATE 7-A -Z, FACILITY TYPE PCHD COMPLAINT # 2!f-�/
PROPOSED INSTALLER PHONE # 21- 6o ZS/
ADDRESS 2-7- au�o- r 5 L w 7�uer�.�_ a-� 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
fl— —A nvfnnf of fhn rnnnir
I, as owner,agree,to the conditions stated on this form
SIGNATURE A °t % TITLE ntok:. y DATE -3 ' J g r W
(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 w/th he ol lowing 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.
1 \ITC11�1 �1 11^c Akll V
Proposal Approved B� Proposal Denied ❑
Inspector's i5ignature & Title Date ExoiratidrYbate
Repair proposal is in compliance with applicable codes Yes No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Date: a-t-` --�
Street Location,
Town:
/),
Putnam County bepartment of Health
Division of Environmental Health Services
SSTS Repair - Fin to Inspection
Inspected by S ' Installer:
_ w.. t M ttim e *Permit #• TM # ) �� - 7 3
/�- -�S�-1 -
Additional Comments:
RFSI Rev - 011312
.1. 1jrpe of System: Conventional 4YAlternate ❑ Comments: �j'� /� /"
2. Septic Tank
Yes
No
N/A
Comments
a. Septic tank size -1,000 ... 1,250 ... other .....
Coe,',S J
i s e Y
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
d. Distribution Bog
i. All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
W. Minimum 2 ft. Original soil between box &
trenches
e. Junction Box - Ooperly set ............................
f. Trenches
i. System �ompletely opened for inspection
ii. Length required Length installed
iii. Pie slope checked ... ...............................
iv. Installed according to plan ...................,..
(fiu l
V. 10 ft. from property line - 20 ft - foundations ...
vi. Size of gravel % -1 % " diameter clean .........
vii. Depth of gravel in trench 12" minimum .........
viii. Ends capped .... ...............................
R. Pump or Dosed Svstems
3. Sewa e System Area
a. SSTS Area located as per approved plans
b. Fill section -
c. Distance from water course /wetlands
4. Overall Workmanship
a. Boxes properly grouted and installed correctly ...........
b. All pipes flush with inside of box .........................
c. Backfill material contains stones <4" diameter .........
d. Curtain drain & standpipes installed according to plan
e. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
RFSI Rev - 011312
,
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
REQUEST FOR FIELD TESTING
All information must be•uy completed prior to any schedrtling. Date: _ �� 13 -Z6 M
Engineer or Firm: A ao-w
Person to Contact: _ l Nov. Zvi 6c- IT-
❑ New Construction e2e
epair Program ❑
Reason: � Deeps res ❑ Pump Test
Road /Street:
V
Phone
Addition Program
Town: Tax Map #: %31
Subdivision: Lot #:
Owner: GINc \ S -e-
El Project not within NYC Watershed.
NYCDEP CRITERIA FOR .IOPiT REVIEW AND WITNESSING OF SOIL TESTLNG
YES NO
❑ ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner
reservoirs.
❑ ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
❑ ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
❑ ❑ Proposed SSTS design Clow 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.
This 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 Geld testing with the Design Professions 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:
COM titENTS:
}
Req.for field test:kly 4/16/2009
PUTNAVI COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner: / Address:
Located at (street): �� 06V'1-) roc... /f TM # Sectinn,3� Rtnc►3 Nit
Municipality: �c�J�n Watershed:
SOIL PERCOLATION TEST DATA
/ Witnessed by:
Date of Pre - soaking: ��/b� /Z Date of Percolation Test: 7?
a.
Hole No.
-
Run No.
Time
Start —
Stop
Elapse
Time
(min,)
Depth to .
water from
ground
surface
(inches)
Start - Stop
dater
level drop
in inches
Percolation
Rate
min/inch
2�
I
e
c7
2
2
3
-- /S�
2�Z_
,21
7
4
,
5
I
�
2
3
4
I
2
3
4
I
.
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., < t min for 1-30 min/inch. < 2 min for 31-60 miniinch).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97, pg I of''_
TEST PIT DATA ,
DESCRIPTION OF SOII;S ENCOUNTERED IN TEST HOLES
DEPTH HOLE #� HOLE # HOLE # HOLE # HOLE #
G.L. a�
orb
0
2.5'
3.0i 1 `
3.5
4.0'
4.5'
5.0'
5.5..
6.0' .
6.5'
8.0'
8.5'
9.0'
9.5'
10.0'
Indicate level.at which groundwater is encountered /v AV
.Indicate level at which mottling is observed A//A
Indicate level to which water level rises after being encountered
Deep hole observations made by: C,z Date / /Z
Design Professional Name:
Address:
Signature:
Design Professional = Seal
DEPARTMENT OF HEALTH
vision of Environmental Health Services
Geneva Road, Brewster, New York 10509
(914) 278 -6130
PLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #WIO-OLI
WELL LOCATION
S treet ddress
, (-A
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/�'
1 age City Tax
/
Gri N er
WELL OWNER
Name
M ilin, Address
S4^4
jurrivate
O Public
USE OF WELL
1 - primary
2- secondary
IDENTIAL
0 BUSINESS
0 INDUSTRIAL
(3 PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
❑AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
13ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 4;6'0 gal
REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION Gl ADDITIONAL SUPPLY
O NEW SUPPLY ' NEW DWELLING 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
'i's
JAIr
file j 11
14 jg'
WELL TYPE.
DRILLED
DRIVEN
®DUG
®GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
i
WATER WELL CONTRACTOR: Name 7t &)-I< Address : elf 31 10 OK 61
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET ��� �
OateY (signa
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirt3* (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall to ppropriate action to assure that
any and all water or waste products from such well drills g op ration be contained on this
property and in such a f an er as not to degrade or other a on tam' a surface o groundwater.
Date of Issue: , , 19 _
Date of Expiration ;; L 19 Perm suing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
JOHN KARELL Jr., P.E., M.S.
Public Health Director
41�w'Ox -216
Re: "Addition
Dear
I have received and reviewed the plans for the proposed addition to the above
mentioned residence.
The plans have been approved as per plans bearing this Departments stamp and
dated V -/7
The survey indicates that sufficient area exists to expand or repair the sewage
disposal system, should it become necessary in the future. Therefore, based on
the information submitted, the above mentioned addition is approved with the
following conditions:
1. The total number of bedrooms must remain at _ without prior approval
by this Department.
2. The area of the existing sewage disposal system, and its expansion area, must
be maintained.
3. All plumbing fixtures must be replaced or updated with water saving devices,
i.e., low flush toilets, restrictors for shower heads and faucets, etc.
Approval is granted for sewage disposal only. Any other permits or variances
requa d r the responsibility of the applicant and the jurisdiction of the Town
If you have any questions, please contact me at your convenience.
Very truly yours,
Assistant Public Health Engineer
RM /jp
cc: BI ( T ) • t/00- 5047
--------------- - - - --
FORM: STAMPED ADDITION
Assistant Public Health Engineer
RM /jp
cc: BI ( T ) • t/00- 5047
--------------- - - - --
FORM: STAMPED ADDITION
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PUUtnBm COUntY Department of
jivtai of vi nmental Health Servicea
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.pplicable Rules and Regulation of the
Putnam County-Health Department.
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SCALE: IO = 301 AUGL
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FROM AN ACTUAL SURVEY OF. TOE I
SURVEY COMPLETED AUGUST I,
M AP COMPLETED AUGUST 3,
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
14 -7
-2
-2/
t7
Dear
JOHN KARELL Jr.. P.E. M.S.
Public Health Director
`7
Re: `Addition �Y/
Go 217 e,61e11 A
--7 "4f- >'�-
I have received and reviewed the plans for the proposed addition to the above
mentioned residence.
The plans have been approved as per plans bearing this Departments stamp and
dated -S 10041116--/r / r;p y
The survey indicates that sufficient area exists to expand or repair the sewage
disposal system, should it become necessary in the future. Therefore, based on
the information submitted, the above mentioned addition is.anproved with the
following conditions:
1. The total number of bedrooms must remain at _ without prior approval
by this Department.
2. The area of the existing sewage disposal system, and its expansion area, must
be maintained.
3. A11 plumbing fixtures must be replaced or updated with water saving devices,
i.e., low flush toilets, restrictors for shower heads and faucets, etc.
Approval is granted for sewage disposal only. Any other permits or variances
requived are the responsibility of the applicant and the jurisdiction of the Town
of�►�
If you have any questions, please contact me at your convenience.
Very truly yours,
Assistant Public Health Engineer
R/jp
cc: EI (T)
FORM: STAMPED ADDITION