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00747
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PRXPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
YES N internal Use Only PERMIT # —1
[I Repair Permit issued in last 5 years ❑ Not in Watershed
[� Repair within Boyd's Corners, W. Branch or Croton Falls Res. �( Delegated
- 0-4rOA I
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION u 3 R-4- i6L( TOWN k4,[, TM #
OWNER'S NAME )�051e mgui -(- . ?.&Cr'i A PHONE # ?7? *- b a 7q
MAILING ADDRESS 3g3 ' "'(,� -(
APPLICANT .�S C�xc cr3Vt�tTj ta e-
Name & Relationship (i.e., owner, tenant, contractor)
DATE /o? �p� FACILITY TYPE �C. 7a� PCHD COMPLAINT #
PROPOSED INSTALLER PHONE # EL S� a�6�ag,41 X d; ✓
ADDRESS 131 OtCA 12 . S1 S --Orm, I It REGISTRATION /LICENSE # _PC
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 on1he
nature and extent of the repair. S�c� j L orjjil,' 1600 (� "W. t �' ��w
it�nl�ck Soo C1& s�-c.! .Sef�r'c. ?av► /� ;��� 41-
�i�s
I, as owner,agree to the conditions stand on this form
S
� rZ-Li,k'.o 'n lei kc ,ice IS er,L
SIGNATURE TITLE DATE QS' 3b a
(owner)
f, the septic installer, agree to comply, wit the conditions of this.permit for the septic system repair y
SIGNATURE � ��% Avg TITLE ��'C� DATE S V p �
(installer) \
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
�2 bmission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
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
A. 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.
yj INTERNAL USE ONLY
Proposal Approve r i Proposal Denied
ctor's Signature & Title C 0
is in comoliance with applicable codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
426
Date I Expiration Date
Yes ❑ No ❑
Rev. 2/07
4
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
PROPOSAL FOR..EXPLORATION OF SEPTIC SYSTEM FAILURE
All 'information below must be fully completed prior to any scheduling
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
3 GO k- I i9 1/
(6y
TOWN
PHONE #
ti, �y l SSG 3
TM •aY-
PROPOSED CONTRACTOR /INSTALLER /7' n� PHONE
ADDRESS j 3� `��`� �C�c f� S�v�n�� �Ce REGISTRATION /LICENSE # t i o2
R. ason for exploration.,
lure to: surface back -up in hously- nd limits of system for repair ❑ other (explain below)
FOR COUNTY USE ONLY
nscegfor's Signature & Tide Data
o jo
Appointment Date; I (me:
r j` - 3113 a, 3(/6
kiy:excei:septic
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
ROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAI
LaR
Ft9os��p O Internal Use Only PERMIT #�
❑ Repair Permit issued in last 5 years ❑ t in Watershed
❑ Re pair within Boyd's Corners, W. Branch or Croton Falls Res. elegated
❑ Repair within 200 ft. of a watercourse or DEC- pped wetland d01 RBVI @W
SITE LOCATION
OWNER'S NAME
� p OWN ��� / /�Y'St�n/ TM #
S /EE C / /\ PHONE #
�r_—
-f )�' -�y
MAILING ADDRESS \3 "� E oL) l6 1 15/ aL� - w:
APPLICANT G'Si �J� �EC'.J� /N ��i -��✓'V �'__;
Name & Relationship (i.e., owner, tenant, contractor)
DATE G' /( ^ =0 FACILITY TYPE A7bl)S PCHD COMPLAINT #
PROPOSED INSTALLER "� j� S E'X eatkj 64 PHONE # g
r'
ADDRESS 1'3'1 oto( 124-e !S�L a�ot�mI,;III ASS/ a 512,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
na r aer extent of the re air. I
I, as owner,agree taihe conditions stated on this form
SIGNATURE/ /L G'�?,Gf/LcL' /� �/L� TITLE &QA)&7`b DATE 03 -16 "U
(owner)
I, the septic installer, ee to comply with the conditions. of this.permit for the septic system repair
SIGNATURE TITLE DATE 6
(installer)
Proposal an ved with the followino 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
Prop�osjal A�pprov t1X Pr osal Denied
;tor's Signature & Title r`
r proposal is in compliance with applicable codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Date' Expi
Yes E) No
Rev. 2/07
C , 5'
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MEMORY TRANSMISSION REPORT
TIME MAR 718 -2009 03:54PM
TEL NUMBER : 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 671
DATE MAR -18 03:52PM
TO 919147730343
DOCUMENT PAGES 004
START TIME MAR -18 03:53PM
END TIME : MAR -18 03:54PM
SENT PAGES 004
STATUS OK
FILE NUMBER 671 * ** SUCCESSFUL-TX NOT ICE * **
PLITiJAfvl GO1,.lNTY i-- IEALTH OEPARTh/lEN T
OI\/(SION OF cfJVIRONMcNTA4 HEALTH SER\./ICE:S O
P OPOSAL FOR S =WAGE TREATMEN SYSTEM R PAIR
YE `,� O Into rnal L15e Only PERMIT aV
CJ Repair Perrntc Isau etl In lass s years t In W 8tersrled
� Repair wi[nln Boyd'a Comara. W. Bre 1, or Croton F- IMi=loa_ aICgF3tOd
Repair within Zoo it. of a wa[ercouretr or DEG- p ed-watlantl JOi Review
SITE LOCATION �TQ�/t/N A T �-s U n% TM IV — `-
OWNER'S NAME; -, PHONE W -
MAILING PPRESS G i O
APPLICANT
Neme 6 Raletionship (,_c., owner, tenant, conrrrrayctor)
DATE G =a - %_ -- U ` FACILITY TYPE IL�s P01-10 COMPLAINT aY
PROPOSED INSTA" F-FR � �r 5 X ��i-F'�''y /►� c - PF -(ONE #
ADDRESS �3'i o �i �•M,�_ S?. ci�9orw.•,j t /i►.iV REGISTRATION /LICENSE iV
Pr000aal (Include a separate sicatch.locating the h.ousa, property Iinas,. all adjacent wells within 200
feet of repair and thte.location of existing and plroposad system)
NOTE: The Dapartment may require submittal of proposal from licensed protessional dapenciing on the
nerstre avrtlextent of the repair. • i _ -/ I /S). _ / ,., ��/` '� �..- +_�- •L -„-�.�
,/u: S Cj� --}-rte acr i.� Gi - J✓rCG rat S ,�..,�J r_b/
1, as ownar,agraeJ - t;,)'tg ondltions s d d on IS farm
SIGNATURE'/ /G�.dYYL[2iLa.G ='� - �/!/Li J TITLE DATE G��
(owner) '
I, the septic Installer Be to comply with the conditions of this permit tar the septic system repair
SIGNATt9RE TITI���s�iw.�i DATE
(installer)
I . Procurernent of any Town P®rmit, If appticabla.
2- Submission of ats built repair sketch by the septic systerri installer within 30 days of tha ropalr. in duplicate whowing:,
a. Owners name, Stte Street Name, Town and Tax Map number
b. Location of Installad.componants tied to two Taxed points -
c. System demcrlption (e_g_, 1250 gal. Concrete septic tank, etc_)
d. Installers name and phone number
3. System repair to be poriormed- in accordance with the above proposal and conditions
4. The proposed SSTS repair is coneidered a best fit design.and there is no guarantor•,. to the duration at which the
completed SSTS repslr will function:
5. No completod work (s to be bockfilled until authorization to do so has been obtalnod from the Deportmont.
INTERTIC.L USE ONLY
Prop sal Appro �f F. osal Deniad
tns actor's Signature U,. Title �i0��7 !i-
Gate( Er_Pi, tlon sta
COPIES: PCHD; Owner; Installer
PC -;RP 09KAL
r -
Rev. 2/07
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION .OF ENVIRONMENTAL HEALTH SERVICES
DESIGN. DATA SHEET — SUBSURFACE SEWAGE'TREATMENT SYSTEM
(1-1 P2
Owner:
Address:
Located at (street): put'' T . M # Sectiort'�—Y Block I' Lot
Municipality: Watershed: t2s'A'
22
SOIL PERCOLATION TEST DATA
L Witnessed by:
Date of Pre - soaking: Date of Percolation Test: -3 < '7 /0
Hole No.
Run No.:
Time
Start
Stop
= Elapse
Time .
(min.)
Depth to
water from
ground
surface
(inches)
Start . Stoo
Water
level drop
in inches
Percolation
Rate
min/inch
2
1 10
30
21W
3 .73;
to 3,
3 o
4
5
3
4
7
5
2
3
4
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., < 1 min for 1-30 min/inch, <2 min for '31-60, min/inch)
All data to be submitted for review.
2. Depth measurements to be made from too of hole.
0
� t le5-
M AP O F S U R V E Y Y
P 0 K T 1 0 N OF P N O P E K T Y OF
MADE
FROM AW ACTUAL SURVf-vj of THE PROPERTY.
5 U NV EY COMPLETED tij y 24
jDC,5
M A (> CO M PLET E-D J U N E to
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5 F-1-t GL
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Pul-t-INM cout.,I-ry
(a R E V4.S T G- P, -, NEW
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S A V i N G -S P, t<
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I C E R T I F Y T H A T T H 15 MAP WAS
MADE
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5 U NV EY COMPLETED tij y 24
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I C E R T I F Y T H A T T H 15 MAP WAS
MADE
FROM AW ACTUAL SURVf-vj of THE PROPERTY.
5 U NV EY COMPLETED tij y 24
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PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Wallace and Rosemarie Perrin
Route 164
Patterson, New York 12563
Dear Mr. & Mrs. Perrin:
ENID L. CARRUTH, M.P.H.
Public Health Director
JOHN KARELL Jr., P.E.
Director
January 31, 1989
Re: Proposed addition to existing residence
Perrin, Route 164, Patterson
Tax Map # 15 -4 -4
I have received and reviewed the plans for the proposed addition to the
above mentioned residence. The plans indicate that a 12' x 26'
addition will be added to the south side of the residence.
The residence is presently a 3 bedroom structure. The well is located
on the south side of the parcel, and the sewage disposal system on the
north. The system was recently reconstructed and consists of a 1000
gallon septic tank and approximately 240 feet of fields.
A field inspection on January 20, 1989 indicates that adequate room
exists to expand or repair the system, should it become necessary in
the future.
Based on the information submitted, the proposed addition is approved
with the following conditions.
1. The residence must remain a three bedroom residence without prior
approval by this Department.
2. The north portion of the parcel must be maintained for possible
expansion of the sewage disposal system.
3. All plumbing fixtures must be replaced or updated with water saving
devices. i.e., low flush toilets, flow restrictors for faucets,
showers, etc.
Perrin -2- January 31, 1989
Approval is for sewage disposal only. 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 concerning this matter please contact me at
your convenience.
Very truly yours,
William Hedges
Sr. Public. Health Sanitarian
WH /'jP
BI (T) Patterson
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WALLACE 6 ROSEKARIE PERRIN
RT. 164
PATTER SON, NEW YORK
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