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LORETTA MOLINARI
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Lydia Prophet
C/o Kevin Molner
34 Hiawatha Road
Putnam Valley, NY 10579
Dear Ms. Prophet:
ROBERT J. BONDI
County Executive
November 7, 2003
Re: Addition — Prophet
37 Deacon Smith Hill Road
No Increase in Number of Bedrooms
(T) Patterson
TM# 23.13 -1 -21
I have received and reviewed the plans for the proposed addition to the above - mentioned
residence. The proposal for the addition has been approved as per plans bearing the
approval stamp from this Department dated November 7, 2003. The addition is
approved with the following conditions:
1. The total number of bedrooms must remain at Four 4 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 updated with water saving devices, i.e., new low
flush toilets, restrictors for shower heads and faucets, etc.
Any other permits or variances required are the responsibility of the applicant and the
jurisdiction of the Town of Patterson.
If you have any questions, please contact me at your convenience.
Very truly yours,
Michael Luke
Public Health Sanitarian
ML /jp
cc: BI (T) Patterson
LORETTA MOLINARI R.N., M.S.N.
Public Health Director
ROBERT J. BONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Lydia Prophet
c/o Kevin Molner
34 Hiawatha Rd.
Putnam Valley, NY 10579
Dear Ms. Prophet:
October 24, 2003
Re: Addition — Prophet, 37 Deacon Smith Hill Rd.
(T)Patterson, TM #23.13 -1 -21
I have received and reviewed the plans for the proposed addition at the above mentioned residence.
The plans indicate that the proposed addition will consist of the following:
Rearranging the first floor.
Based on the information submitted, the above - mentioned addition cannot be approved for the
following reasons:
1. The library is considered a potential bedroom.
2. The legal bedroom count for the dwelling is four. The potential bedroom count of your
proposed addition is five.
3. The addition of a potential bedroom requires this Department's approval of a revised septic
system plan from a professional engineer.
Please revise the proposed floor plan to reflect no more than four potential bedrooms, or have a
professional engineer or registered architect design a sub - surface sewage treatment system meeting
present code requirements.
If you have any questions, please contact me at your convenience.
ML :lm
Very truly yours,
C'
Michael Luke
Public Health Sanitarian
ergonomic design 34 hiawatha road tto putnam valley ny 10579
October 31, 2003
RE: Prophet Residence, 37 Deacon Smith Hill Road, Patterson, NY. 12563
TM #23.13 -1 -21
Department of Health
Attn. Mr. Michael Luke
1 Geneva Road
Brewster, New York 10509
Dear Mr. Luke,
Enclosed you will find the revised drawing in reaction to your letter dated October 24,
2003 and our subsequent telephone conversation on Tuesday, October 28, 2003. As
discussed I have removed the door and frame and enlarged the existing opening to 4'-
0" dimension there by taking away any reasonable privacy from the room and in the
process removing it as a potential bedroom. Therefore the bedroom count will remain
at 4 and no work to the septic system will be required. If you should have any questions
or further comment please feel free to contact me at 914.572.0366.
Sincerely yo
aj2oo
I�L
Kevin E. Molnar
ergonomic design
0
LORETTA MOLINARI R.N., M.S.N.
Public Health Director
ROBERT J. BONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Lydia Prophet
c/o Kevin Molner
34 Hiawatha Rd.
Putnam Valley, NY 10579
Dear Ms. Prophet:
October 24, 2003
Re: Addition -- Prophet, 37 Deacon Smith Hill Rd.
(T)Patterson, TM #23.13 -1 -21
I have received and reviewed the plans for the proposed addition at the above mentioned residence.
The plans indicate that the proposed addition will consist of the following:
Rearranging the first floor.
Based on the information submitted, the above - mentioned addition cannot be approved for the
following reasons:
1. The library is considered a potential bedroom.
2. The legal bedroom count for the dwelling is four. The potential bedroom count of your
proposed addition is five.
3. The addition of a potential bedroom requires this Department's approval of a revised septic
system plan from a professional engineer.
Please revise the proposed floor plan to reflect no more than four potential bedrooms, or have a
professional engineer or registered architect design a sub - surface sewage treatment system meeting
present code requirements.
If you have any questions, please contact me at your convenience.
ML:Im
Very truly yours,
Michael-Luke
Public Health Sanitarian
PUTNAM COUNTY HEALTH DEPT. 025729
1 Geneva Road (845) 278 -6130 -
Brewster, NY 10509 Date _/ d 11Q 1o3
Received of
The Sum Of Dollars $ O 0 a
For c 3 V? d3
THANK YOU!
❑ Cash Q Check [1 0. Q Credit Card By
l 1 1 1 1 1 1 1 1
y
DEPARUMMNTI OF I-MALTH
Div lion of Environmental Health Services
4 Genava Road
Brewster, New York 105oS+
Tel. (914) 278.6130 Fax (914) 278 - 7911
BRUCE K FOLEY
Public Hzcirh Dir_,c_c:
STREET
NA,VIE l.�pl',� P1�vv� -1� PH0�89`�• 878.10 3 PCHD r A 3 � t -03 ._
%i tba qe ADDRESS �M- Nt^Wc-T4A I�p• ,�,rC�t o Vaw�t r�Y lo�i'1
DESCRIPTION OF ADDITION l r(CG�l o f- ?- (J'�oVp'��6-1
\L.NLBER OF E)USTI.'V G BEI)ROONLS_�_ PROPOSED # CF BEDROOrLS_Y_
(Mo;rt cEAr. o: ccC• PANL c e OR
CERTIFICATION FROM BUILDNC INSPECTOR)
*Any addition which is cor,.s:dertd abedioom tequkes formal approval of plss (Coasauction
Permit) prepa:ed by a - rcfessior4 Engineer or Repi' Mred Arch tect in accordance with
aoplicab:e sections of th: Puu= County Sanitary Code.
Please submit t1ds fc= and the f92oMng to Putam County Health Dcpt., 4 Geneva Rd.,
Brewstter, NY 10509, Phone 27S-6-M-
1.
Certified, check or money order for 5100.00
SRztehes of existing floor plan (drawn to scale,. all living area Including basement)
Non - professional sketches are accept:ble
3. Two sets of proposed ' oor plan (dawn to scare, with name, stre -WI, and tar: r--,,p TM)
*No n—proftsslionai sketches are acceptable
4. Copy of survey snowing well and septic. location, to the best of voz k,owledge. Include date
of installation if kr_ovvn: Label all Fells and septic systems witLm 200 feet of the property line.
Contact this office wi..h any questions.
S. Copy of C en. of Occupancy frcm Town or Certification fmm Building Dept. with legal
bedroom court of dwelling.
OFFICE US
commen7.s
>•:b 93 :
t
DEPARTMENT OF HEALTH
Division. Of Environmental Health Services
vene,4 Road, Brewster, New York 10509
(914) 278 -6120 -
Puts:_- County Dept. of Head
4 Geneva Road
3:ewster, NY 10509
Gene men:
BRUCE R._FOLEY. A c
Acting Puhile Mealth. oi-e:1.11
lee e>n W't I&
Rcsid=ce
Tax Map 43,--1 3 --1 — Z/
Town
Accoidi.ng to re;,ords maintained by the Town, the above noted dv.elling
iS
IS NOT
in cotnplian- ;�- with To%ti . code and thte total number of bedrooms ;,n record
is
This inLformation has been obtained from:
CERTIFICATE Or OCCLTPA2�CY:
AS1SESSORS RECORD: t
0-CH;R
uilding ins;ec o
YML ENV I Fi +� +NMFN'I -AI_. SERVICE"'
21 k::c a. s` S t r• c s: t
Y -,r ktr r, t-Ie i ohts, N.Y. 1_059r'
4
14) 24r5-2800
e '° ° 01.01 ri CI.TFNT # #: J. 205 NON =TAT PR +�C E= 'A +:�E 1
�.•ri
2 •'
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t o ►,
DATE/TIME i" ;Ei':'is< ,;'..�t>':�.I. 9S iCt ";.0
FAIR STREET
AFiMEi.., NY 1.0512 REPORT DATE: 02-/1,4/95
MF'I._ I NG :=;.I TE,a DEACON--; SMITH }..I T i.L RD. SAMPLE TYPE. ° E" OTAB1..E
o PATTER'_ ON K I TC HEN TAP PRESERVATIVES: NONE
s ":s_sl: ' Y s ;Y xi ?'s sI i+:"=i..A :: WAL.3..:A► :E TEMPERA1 "i_IRE ° ° n :. 4C;
o
COI. . I FORM METH' MF
NOTE: °
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DATE FLAG PROCEDURE RE:=,1_iI..T 3 +1CIRMAI _ - RANGE
02/10/95 MF T. +::OI _ I FORM. ABSENT /100 ML ABSENT
COMMENTS e
RAs T T3 —ESE R:ESI",ILTS INDICATE THAT THE WATER i WA'�:7 .CWAS NOT) OF A
SANITARY t:��fAL I T `{ A+ :s�:ORY_s I N ' Ts° Ti-IE NEW YORK STATE-
SATISFACTORY
ANC+ EPA FEDERAL DRINKING WATER =: T nNDARI:l: =„ F i IR- THE F'ARAMET,3=R:E.-
TESTED, AT THE TIME OF: C:O .LE T T i sN>
A
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"T '18K _�_—__—_____�__.__
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PUTNAM COUNTY DEPARMr OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner or Purchaser of Building Section Block Lot
Building Constructed by
CA)Z 4Cv, Q ( PL4 Fr'4 !JI k L41 11
Location - Street
Municipality
or I
S -vision Name
I�ef
Subdivision Lot #
Building Type
GUARANM OF SUBSURFACE SEMAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
workmanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has been constructed as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and, regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years immediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal systan, or any
repairs made by me to such system, except where the failure to operate properly is
caused by the willful or negligent act of the occupant of the building'utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environmental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building utilizing
the system. (-% /
Dated this day of 19.
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
,Address
rev. 9/85
mk
Signature`�C
Title
Corporation Name (if Corp.)
Address
WELL COMPLETlUN MtrUK1
* * DEPARTMENT OF HEALTH
rj. Division Of Environmental_ Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET AOURESS: =N/ViLUCILICHY TAX GRID NUMBER:
�® ._... .--f
WELL OWNER
NAME. / ADDRESS:
Zij/a !Q'�. co s,,� v
P81VATE
p PUBLIC
USE OF WELL
1 - primary
2 - secondary
to RESIDENTIAL ❑ PUBLIC SUPPLY O AIRICOND. /HEAT PUMP O ABANDONED
O BUSINESS ❑ FARM O TEST/ OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY O
MOUNT OF USE
YIELD SOUGHT __S_ gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
RfNEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL �ATE
MEASURED
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION O DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH _�LL_ ft-
MATERIALS: STEEL O PLASTIC O OTHER
CASING
DETAILS
LENGTH BELOW GRADE ad ft.
JOINTS: O WELDED O THREADED O OTHER
DIAMETER �� in.
SEAL: CEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT 17 _ Ib. /ft.
I DRIVE SHOE 9YES O NO
I LINER: G YES dfNO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
O YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
70P
DEPTH fL
BOTTOM
DEPTH ft.
WELL YIELD TEST ' If detailed pumping
M HOO: ❑ PUMPED i tests were done is in-
(I COMPRESSED AIR , ! ormation attached?
O BAILED O OTHER ❑ YES ❑ NO
'WELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
in9
We1l
Dia-
peter
FORMATION DESCRIPTION
coot
tt
ft
WELL DEPTH
ft.
DURATION
min.
DRAWDOWN
YIELD
gFm.
Land
t�
ffidle
,hr(,
,ft�..
WATER bf CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? ❑ YES ONO
ANALYSIS ATTACHED? O YES ONO
STORAGE TANK: TYP ES5U a)E11 k�rp I
CAPACITY GAT..
PUMP WFORMATION
TYPE JC�
MAKER -6-C4 4
MODEL
(�
CAPACITY /� 6l •
cl DEPTHS
VOLTAGE HP
WELL DRILLER NAME OATS
ALBERT M. HYATT & SONS, INC.
ADDRESS Well Drilling SIGNATURE
Rte. 311 R.R. 2 L-4ox 171A _�r
PATTERSON, AIEVV YORK 12563 n
y..
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�__ _ _
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- .. Trailed at di�Gg�cJ;_
Renaud Savialm.
Dab r
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d
S11.111— wAd6l..� . �i - .Glen•
.Subdivision ARRroved Enclosed Atnn,iinf_:Bn
-7 ma
RIP Opt" ( OVim' v d.
Number d etiiiea■a P=Nvd&admk wha i lU ls ompfislad
To lw iii?. aJ :iL A
,., !ice DdIsd W,
I rep►Nsnit:ahat 1 am:wh011y aiid plot* responsible for the Wign a location Of the - proposed syptem(g -0 4hat the M ite saw di vl stern
atone dpCrlbed aril) be coinstructed aa°Nwwn,oai-the epproved ime"Milint _tneio to and -in accorden a with th®Standaroe; rum a rotiu M
OwMy- DfaOMtniant of .Ifaafih; and filet on ewnplation,tM►niof,a "Certifkab, of`Construabn.Complknce! tatisfodacy to the CommlYlOnr:of,MMKhw1U -
M'subod"W,to. the pop tnlanl, aeoA;a, written-1pw!""e wUl be furnk+Md tta:owna►. his.sucoemors, hoks or_aoigna.bY. the bull". tNt »id bulk w wlll
pttioe..Mt_ flood ;ojaratbp asyWRloih;ahy• part o/'iad` siwa/o£A6ioos.i syttem ®u►ti� the pwsea of two (f) years hnln%Oiaoly.fotleiwky tMd.to of the- N.u�,;.
aw of iM apMowl al- '4fae' CwtMiiato qf.. Construct , Coniplunca of aM' original W" or;any roppbs jewstoi #'ihat'•th dulled well doaaileed abew
we M located tl /lolelw aw free appaer view and ¢has rata woy will be.InsUtted in •ccoide wale, .the fbn0iratr rules and ,rgiaiio�s of ;;the putnanl_-
ceiiftY Dowtsmom Of "maRO1.
Signed
Et
9
AfMW%#EO roe COMTRU"loRh Yhiiapproeai eapi►of two yaws frowi tho We Issued unless construction of the. building has. boo "undertaken and is
: rimplimbill far C40JU or may N aww"m or meyified when CO"ddrad commissioner of Health. Any then" o►- alteration of constructlOQ . .
06"ires_ new permIL ' 61 bate etw ,suprp#y, only
$
10 /88 ��� -
,
pUrNAM COUNTY DEPAi TMERr . OF HEALTH
DIVISION OF RTJ1PLNMUqML HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL. SYSTEM FILE NO.
Owner P�;O(e (A-4UL AC Z Address ( �.J ern v�' ► �- ��
Located at (Street) �i�41R s-���'-. " `sec. Block �,_ Lot
(indicate nearest cross street)
®� tai
Municipality Watershed �
c,0TL PERCOLATION TEST DATA REQU= TO BE SUBMITTED W= APPLICATIONS
Date of Pre- Scaking `Date,of.Percolation Test
EOLE
ND= CLOCK TIME - PMCOLATION PERCOLATION
Run
No.
Elapse - Depth ,to Water Fran
Time. Gro,;rd Sarface
Start -Stop Min. Start Stop
Inches Inches
Y*---ter Level
I.n Inches Soil Rate
Drop In Min /In Drop
Inches
q
2
G1�
12��.�3
P02
3
Ot5*LAY-�
f;01ZM
. 4 A C>V� 4 .- �L - P-g, 75� - - t-Y--f -
G1
2
3
4
5
l
2
3
4'
5
NOTFS:f. 1. Tests to be repeated at 'same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be sibmitted
for review.
2. Depth measurewnts to be made fram top of hole.
14!
INDICATE LEVEL AT WHICH GROUNIXATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEE, RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used �S -�'� Min /1" Drop: S.D. Usable Area Provided
No. of Bedrooms 3 Septic Tank Capacity gals. Type
Absorption Area Provided By 37 ✓` - L.F. x 24" width trench
Other 4;A(, f o "^ P
Name e rv(��� �+4-S ��� Signatur
a Address is &;Ma5�WL 4VUL RO SEAL
02380 y0
THIS SPACE FOR USE BY HEALTH DEPARTMFM ONLY:
Soil Rate Approved sq.f.t /gal. Checked by Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services,
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL ��
PCHD PERMIT #
WELL LOCATION
Street �AAdddr�es�a
R� Town/Village/City Tax Grid Number
WELL OWNER
Name �
W .AC,0
Mailing Address
440- GI M'
rivate
0 Public
USE OF WELL
1 - nrimar*
2- secondary
tf.ItESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
b INSTITUTIONAL 0 STAND -BY
0 ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 606 gal
❑ REPLACE EXISTING SUPPLY O TEST/ OBSERVATION LLADDITIONAL SUPPLY
ILNEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
es s o esac.v
WELL TYPE
DRILLED
DRIVEN
E]DUG
[]GRAVED
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Va[a $t-, SJgD1 IS10N
Lot No.
WATER WELL CONTRACTOR: Name -44 -mot Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: t7iy�.iz.
LOCATION SKETCH SOURCES OF CONTAMINATION P.RO D
.SON SEPARATE SHEET
zr_ Qy
(date) ignature)
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
thirty. (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 take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminat surface or groundwater.
Date of Issue: /^ D 19_ -c %3 ��
Date of Expiration 19� Permit Issuing 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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. f . .,
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�;`;The''spto
i::,'.'' was •�i'nspec
�• , %�Yn',8tcordai
` "-�a• regulation
`ilea3tti�'?and.
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LORETTA MOLINARI
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Prophet
34 Hiawatha Road
Putnam Valley, NY 10579
Dear Ms. Prophet:
June 14, 2004
ROBERT J. BONDI
County Executive
Re: Addition - Prophet, 37 Deacon Smith Hill Rd.
No Increase in Number of Bedrooms
(T) Patterson, TM #23.13 -1 -21
--I-have received and reviewed the -plans- for the proposed addition to the-above= mentioned - -
residence. The proposal for the addition has been approved as per plans bearing the
approval stamp from this Department dated June 14, 2004. The addition is approved
with the following conditions:
_._.... 1. The total number of bedrooms must remain at four 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 updated with water saving devices, i.e.; new low
flush toilets, restrictors for shower heads and faucets, etc.
Any other permits or variances required are the responsibility of the applicant and the
jurisdiction of the Town of Patterson.
If you have any questions, please contact me at your convenience.
Sincerely,
�V� 144
Michael Luke
Public Health Sanitarian
ML:hn
cc:BI (T) Carmel
BRUCE R.. FOLEY
Public Health Director
DEPARTMENT OF HEALTH
LOREI7A MOLINARI RN., M.S.N.
,I.csociate Public Health Director
Di4ctor of Patient Service.,
I Geneva Road I a
Brewster, New York 10509
Environmental Health (&4s)278-6130 Fax (845) 278 - 7921 D
Nursing Services (845) 218 - 6S58 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early intervention (945)278-6014 Preschool (845) 278 -6082 Far (845) 278.6648
ADDITION APPLICATION (RESIDENTIAL ONLY)
STREET 3'1 V MW 12D. TOWN: oOJ Tx MA.P9 2-$ . 122
,NA -m yion lA PHONEW & 1018_ _ 1'CHD9
l�tP�.1gT► -�P Fw-v l PvTNRIV► VPAA4;-f l o0i19 e—/o K • M OLJ#4Z
MAILING ADDRESS C pL-V— f caw q 14 r317,0 40 W tw p t e
DES CRiPTION OF ADDITIW r—A IN 1 Vi aOpM WI ^-TT1 G OV
NTL:�IBER OF EXISTING BEDROOMS 4 PROPOSED # OF BEDROOMS
(FROM CERT. OF OCCUPANCY OR
CERTIFICATION FROM BUILDING INSPECTOR)
'Any addition which is considered a bedroom requires formal approval of plans (Construction Permit)
prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the
Putnam County Sanitary Code.
Please submit this form and the followuig to Putnam County Health Dept., 4 Geneva Road, Brewster, NY
10509, Phone 278 -6130.
1. Certified check or money oider for $100.00.
2. Sketches of existing floor plan (drawn to scale, all living area including basement)
.4 Non-professional sketches are acceptable.
3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map 9)
*Non-professional sketches are acceptable.
4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of
installation if known. Label all wells and septic systems within 200 feet of the property line.
Contact this office with any questions.
5. Copy of Cert. Of 'Occupancy from Town or Certification from Building Dept. with legal bedroom
count of dwelling.
OFFICE USE
Comments
Feb98
BFhousegyidelines
a
GAUCS P . FOLE-Y. A
Attime Public NeAtIM
DIPARTMENT OF HEALTH
0.1 YU on; Of ' WWO MrmentsJ Health Services
Ctneye Road, Brewster, Now York 10509
(914) 275-6130 -
PLU-mm coiurnty Dept. ef Iric.810.,
4 Genev i Road
B :cw=r, NY 105C9
AdO'.
Residence
Tax M X3, - I
'VI
Tots n
I-
Qen6t.men:
Acco; di.ng to rt,.*ordas m ainta'.r.ed by the -Town, the abeye Wed d\velling
is
IS VIDT
in compliall th T3%s I coda. and. the totat number of bedrooms -vn record
This information has been obtained frorr.'.
CERTIFICATE Of OCCUPANCY:
A_ ra
AL 3ES- SORS RECORD-. Xt-
OTHER
wilding lns; cc