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HomeMy WebLinkAbout0682DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.11 -133 f E,{ r ' " PUTNAM COUNTY HEALTH DEPARTMENT DI ISION OF ENVIRONMENTAL HEALTH SERVICES P POSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES N11 Internal Use Only PERMIT ''q' =b ❑ // Repair Permit issued in last 5 years Meleg�ted of in Watershed I ❑ / Repair within Boyd's Corners, W. Branch or Croton Falls Res. ❑ d Repair within 200 ft. of a watercourse or DEC -mapped wetland 1:1 Joint Review SITE LOCATION 33 5(�. 6v R frsi TOWN ty JOA TM # 9J, I/ -- l 33 /OWNER'S NAME J V PHONE # i� 43P "�)d Z ,/MAILING ADDRESS 313 610% mlpr 1 QkAC Ztoe% - N.4 ILU)%1; APPLICANT Name & Relationship (Le:, owner, tenant, contractor) DATE Z-00-7 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER �owa- 1,tl. PHONE # 9W Z79- 6065' ADDRESS `lj'� ,N �& g W, f "-e, REGISTRATION /LICENSE # P<, V 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 ivt cs. �ecL s ys- Ear►.► oQv� � o s� j.7�iYt !, as owner,agree to the conditio s stated on this form w1 .,or 3�n�e 'Aid( 9> —Val aKA aavc� WOO J:& bYa� , SiGNA T UF;E TITLE twr-AA DATE G JI (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE A TITLE !�A, DATE /6. /. 2Qe7 (installer) Proposal approved with the (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. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ 1D// 7/07 .2 spector In 's Signature & itle Date Expircftion Date Repair proposal is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 3 3, r7, -ec�rw /' I %t a. i 9Yj 0 0 o T a J q . ' .,0 F+ . w� ��Ts^2Y �nx 7 N � J D g� 1 �L�� (v►..1 . nn ter[ o�/E9� ( C�R.1 � .'. � — 23.11 -1 -33 LOT W06. (O$--1© 6FG�"IC1w, G ^6,;:, ,p tr-= wr v1 G_vj F1(. eO AAAP RLG -7 -z9 r (n vJ 1.._J C7 P,&zr- 'Ev - --- 0 Kj � � PVT -AAA k G4� V I�- !'T'`C� fir' •'� log Alvc- ren F I E n TL7 r- v T t_.I N� !_c-►u r_fi �/ <.�u � � •1 G �, •. A-A, I- I C-. AJJ . T17 LE S V D A 1,••1 Fe>m Pct L_ I c-e A-L 2--1 ra - 531 G 11�1ca71olJii 1I_IDIC�;rE�; EJE>ZE�t -1 5t4tJl�V °trid.1• ,01.7EP.4?"IC)L.J ci-, 4MAT"IC)" 5L)O\,E.'f WAh PCE- Pkr.MD IU Ar.COr-DAJ -KP. U7)4 -TO 791"? i)AP v7 A VIOLa'T1Cy,.1 cc SE1'1Io1,1"� ElC 15T I LJCs c-oDE_ ' c' PeACT K E. RJ2 UU JC., , T209 C-v 't1SE LI-7.k1 Yr2Y erx.K A-r i". �PrZD e)-emlE. UEW /bek 5fi1;TE_ Al-.- 1 A r%j or Ldkj CjQcE.MP1 t-1.J( JC_ri.X>:.5, IG.:N.I 4 NOV -13 -207 05:02PM FROM - ENVIRONMENTAL HEALTH 8452787921 T -876 P.001 /002 F -029 1 U11Vr -%1V1 VVV111 1 ­­­­ .•••• -••- pI ISION OF ENVIRONMENTAL HEALTH SERVICES P POSAL FOR SEWAGE TREATMENT SYSTEM REP YES N Internal UseOnl PERMIT 7?4�`"+� (,rl Repair Permit Issued In Mast 5 years VDeleg4te�'d of in atershed t U Repair within Boyd's Corners. W. Branch or Croton Falls Res. 1 7 Repair within 200 ft, of a.watercourse or DECC`m,,a�.ppsd wetland ❑ Joint Review SITE LOCATION 33 4(h Wk TOWN �wW\ TM # 23, rte ! 33 /OWNER'S NAME R\aAV2 J `� PHONE # 430 "`4iJ -/MAILING ADDRESS t7) 61r(Jti _ _ Qk C�So'n N --q APPLICANT fl t) r%V '7 Name & Relationship (I.e., owner, tenant, contractor) I DATA z,0-7 -- FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER oc7Gre . w, _ PHONE # Rye', 279 606` ADDRESS ,REGISTRATION /LICENSE # P.C. -- - I 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) I NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of scr the "repair, `a f c o✓ 1, 3 2A. m.. f�rsT /IT - 5K&kvm owe_ 4-o ms) ;Io/.n•rr.oi -dp v , WIt. VSO .g.t v*.L A,ti GOvey- t+/! -{31 !, as owner,agree to the condltio s stated on this form i. &171I/11 UI'iE TITLE tf+'� d� DATE Gi ( v I (owner) the septic Installer, agree to comply with the conditions of this permit-forrthe septic system repair SiGNAT URE TITLE �Gc pATE �. (installer) 41 ProoMtAl AOOM ved i 1. orccurement of any Town Permit, If applicable. I 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 5. 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. S. No completed.work is to be. backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY I PropossfApproved <- 'Proposal Denied ❑ j Inspector's Signature Reoair proposal is in compliance with applicable codes COPIES: PCHD; Owner; Installer PC -RP 99ML /o // 7/07 Date' Expir: ion Daae Yes No I Rev. 2/07 M Y'be, , • i •n r r ( 'E Y ., 01 r .t fir'' •.'r' � � I. ' • I I f 1�- a007 ISO:1 'at &.o ova Y .. 41 1.� ♦� I cp" � `4 (1t \Z,) . .,,,,,..., ....w -• ... �.t a tiVf „f , �' •°� 760 i�ftl- 23.11 1 X33! •, . • .1. G� � •l�1Fl- tai � r [16 : ^� R, _ 1 � � "try - - \•/ i T �lyv .. r1 �`� .�� �i f�•�.V �7 i_. 'fit a'f�. 1 -��-+^%t —�_ 4_ •¢ ��'. r j. _ �'` J'% i• IJ i "x.o Y Y .L - 1 ..!55 �"�Y_: y `F Y Y' N'. IY•� rT �s�ji 't• OW -4e_ ,.f - ? l': T'e,ti y^FSyr�w''''#..r _.r"f _ ..' ~l ) I �Y�•"ny t. ,A f • l'.� TT Y "fa. .... _... � ;ifr>. `��J�,,F`� �,iy" ,z, r� f2 ijl.� I4�""''• �%,.,•. _.•.w•' ,,�•�fyy��(.. �_ � �.xf . 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Date -of Pre - °soaking fj //:.3 % r y Date of Percolation Test .......... I 1 � 3 a'03 -- 1113:3 4 6i 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, s 2 min for 31 =60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 y 2 3 4 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, s 2 min for 31 =60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.51 1.01 1.51 2.0' 2.5' 3.0' 3.5' 4001 4.51 5ff.. 5.51 6.0' 6.51 740' 75 Kof 8.5' 9:0, 9.5__._ -- 10.0 TEST PIT DATA DESCRIPTION OF SOMS ENCOUNTERED 'IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. Indicate level, at which - groundwater ,is encountered Indicate level at which. mottling is observed ',xigmg., Indicate level to which water level rises after being encountered ry Deep hole obseati ons . made by: _67, T&j -sr., �.x Date 7 Design Professional Name: Address: Signature: Design Profesgionad's SeAl PA I Ral X - -� — qln I - i,•ua� 1 h •- o I R411 mmq E W a O !y M It 1. in -,t a r.: �. ', ' { :y ;Y...' , _� '_+ } -•1 - I 1 l; :- 1 3 11�,' I ^'.. grt, 8 r .`C �l,ll� �� _ 1 � •ul I h I •IYw. 1 .1 t l 2 8_ pl, 1 @p `� � r �f r a x •� `� a° h` a ` lY � id h a � � � r •1 $ r k I f ro '•,�' � —�� `� - I k� yam`` a r r r f ram w Y n - n l h r �.m tt z a m a m �a - ���? s as qtt •\ = r ' -, n mot mm '? i � �•' \ l i —�C O `` 1 as D m e %u 1 .• � 8 R.a M � l i�� t` • w / Q i a+� it d l ,FO JJ •� ♦ n` 7 o V 1 r I Y •u ° ,