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Home My WebLink About0686DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.11 -1-47 1 �. J ' IN - ' T ' 1 6 T '71' SITE LOCATION y� (��' �a— TOWN TM #- 3o..Z� j -y OWNER'S NAME �� ` 2 )P— PHONE #'�(� %� MAILING ADDRESS APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE Z U FACILITY TYPE PCHD COMPLAINT # PROPOSED INS ALLER c3v7- 4fL�i LV�� \ \O �C2i'11�cJ� PHONE # ADDRESS pcv 2..r L(\.j REGISTRATION /LICENSE # _ k Q 2 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, _ A�aSric , _ _ I, as owner,agr athgeGeKitions stated an this form SIGNATURE IT LE C9 � DATE (owner) I, the septic installer, agree to comply with the conditions of this. permit for the septic system repair SIGNATURE TITLE OwrJ&�— DATE --11,2glc) LF (installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 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. No completed work is to be backfilled until authorization. to do so has been obtained from the Department. INTERNAL USE ONLY al Signature & Title Repair proposal is in Proposal Denied ance with applicable codes No Date Yes dg Vd Expir ion Date No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Q (F, -�- I G � �3o 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESI�GnN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address 11"Vk_ ilo Located at (Street)/q i Gvk l : q kA41_,1 VA, �'�' Tax Map 03.11 Block Lot q � (indicate nearest cross street) Municipality Aw He Watershed 6--s SOIL PERCOLATION TEST DATA Date of Pre-soaking I �yl n � Date of Percolation Test NOTES: 1. Tests to he reheated at same denth until annroximately eoual nercolation rates are obtained at each percolation test hole. (ix, 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 From Ground Level 'Percolation Run No Tatue Start Ala se Time Surface (1Ggches) Stogy biro In Rats M�WInch Wei StopM'Itn) Stan Inces 5 1 2 3 4 5 1 2 3 4 5 NOTES: 1. Tests to he reheated at same denth until annroximately eoual nercolation rates are obtained at each percolation test hole. (ix, 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 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. G.L. ,3L- 0.5' 1.0' 1.5' 2.0' 2.5' 1 '1 3.0' 3.5' 4.0' 30 - �d��,w: °� 4.5' 5.0' fu psi- 5.51 6.5' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' HOLE NO. HOLE NO. w i NI �� Indicate level at which groundwater s encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered �� Deep hole observations made by: joe o,,� 4 , �%P MR (Aoi c - Date Design Professional Name: Address: Signature: Design Professional's Seal 2 �� 1 80> > �s �Q "o�2ds� r)2. sue,, Q May 14 08 11:0,7a Roy Barticciotto 878 -6578 p.1 Water & Wastewater Specialists LLC 59 Healey Lane — Stormville, New York 12582 Phone 845 878 -9711 — Fax 845 878 -6578 Roy Barticciotto NYS Certified Water & Wastewater Operator Sally Barticciotto NYS Certified Water Operator & Services Coordinator FACSIMILE TRANSMITTAL SHEET To: L/ Frorn:C:S-,0 �Q r/ Company: N Date: S " 1 -0 LS Fax # "l S a 7 ` f Total pages (Inc. coven Re: C5�C-10 t 1 G 0 ! Mnv 14 08 11:07a Roy Barticciotto 878 -6578 p.2 SITE LOCATION I�� I �a�_ TOWN p �� TM #/ OWNERS NAME PHONE MAILING ADDRESS A in? APPLICANT Co Nft ( A C- Name & Relationship (,e., owner, tenant, contractor) DATE �. 4 FACILITY TYPE PCHD COMPLAINT PROPOSED INS ALLER r3�}TL 41 o Ce aPHONE # �� t; r., ( �� ADDRESS -t Lei REGISTRATION /LICENSE 4 l C) 4 Z Pr000sal (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, t�a 0 " e t c. -+A rJ L nt `cJS I, as owner,agr n this foam SIGNATUR TLE 0 r ✓� DATE f $t O (owner) I, the septic installer, agree to comply with the conditions of this.permit for the septic system repair SIGNATURE TITLE OwnJ CA- DATE (installer) -*'- Proposal approved with the following conditions: 1. Procurement -of any Town Permit, If applicable. Submission of as built repair sketch by the septic system installer within 30 days ofthe repair, in duplicate 'snowing: 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. j 5 No completed work is to be backfilled until authorization to do so has been obtained from the Department INTERNAL USE ONLY Proposal App ctoes Signature & Title at is in compliance with COPIES: PCHD; Owner; Installer PC -RP 99ML Proposal Denied ❑ �' I Date e codes Yes ,6 r o � E.Xpir ion Date No 0 Rev. 2107 May 14 08 11:07a Roy Bartiociotto 878 -6578 p•3 00-1, 147 Route 164 A to Inlet � fr e B to Inlet • A to Outlet �� f ( B to Outlet A to Beginning of trench t r t B to Beginning of trench I / N , (� A to End of trench I B to End of trench I v2 A to Beginning of trench 2 � Zia ! 7 B to Beginning of trench 2 u � A to End of trench 2 �.,C r % B to End of trench 2 r it el % (o