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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
YES NO Internal Use Only���—V
❑ Repair Permit issued in last 5 years ❑ Wit in Watershed 1
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. l_`! Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland r ON . ❑ Joint Review
SITE LOCATION
OWNER'S NAME
✓TM# ?S, �O ,2— !
PHONE #
MAILING ADDRESS rivie kLa=&J
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APPLICANT��`r- ��p(,t, I,oSQ
Name & Relationship (i.e., owner, tenant, contractor
DATE
FACILITY TYPE
PCHD COMPLAINT #
PROPOSED INSTALLER
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PHONE # I IS—F32 ^.J4
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67 gY
ADDRESS q ��`j✓j� /Q,�1�1/, n, ola,' NKEGISTRATION /LICENSE # K I pS®
Proposal (include a separate sketch locating the house; property lines, all adjacent wells within 260
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
I, as owner, or r ort ent owner agree to the conditions stated on this form
SIGNATURE TITLE DATE g/2
Proposal aporoved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditions.
Proposal Approved Proposal Denied �[
Inspectors Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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Sheet _of -�-
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF- ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
Street - Town State Zip
PERSON IN CHARGE
nR INTER VIEWFTI: ��v c2�5 � o�T I G T�atP_ �' �'S�e %
Name and Title
TYPE OF FACILITY: PA / x
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Signature and Title `
RFLORT RFC'FTVF -D RV;
I acknowledge receipt of this report: SIGNATURE:
02/96 Title;
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PUTNAM COUNTY DEPAR NT 0F, ,HEAILTH
DI ISION- Off' EN'VIRON,.ENTAL HEALTH SE VICES
DESIGN DATA SHEET SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner
.Address _7_� 13 Z 171
Located at (Street) Tax'M a.6746Blodk ;L- Lot
indic "te nearest cross street)
-
Municipality Watershed ,x.4457'
SOIL PEtC1LATION TEST DATA
Date °ofPre- soaking 0 7 Date -of Percolation Test
l lv�oo -110108 g 3 0 33 •?
2 /O;oq- lou3 33
3 lord 6 /0,11,0 / 1{ 3 c-r — 33' 3 7
4
5
l --
2
3.
4
5...
l
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
t ?,V,/
41
sA- /.'
Indicate level-at which -grouLndwat-er.,is.,,encountered
Indicate level at which. mottling. is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: Date
Design Professional Name:
Address:
Signature:
Design Proifesgionail`s Se
� [7
2
TEST PIT DATA
DESCRIPTION OF SOILS' NCOUNTERED IN TEST HOLES
-DEPTH
_.____...._ HOLE NO: HOLE NO. --HOLE NO.- -
G.L.
1.01
1.5
2.0'
-S., 4 Y_ /10ja
2.51
3.0
.
3 .5'
400'
4.5
M '
ve 4
5..5
6.01
6.5
7ff
7.5
8o0f
.13 oil
8.51
9-.0,
10.01
Indicate level-at which -grouLndwat-er.,is.,,encountered
Indicate level at which. mottling. is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: Date
Design Professional Name:
Address:
Signature:
Design Proifesgionail`s Se
� [7
2
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PR POSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR , w�
NO Internal Use Only
❑ Repair Permit issued in last 5 years ❑ t in WatersheP I
❑ (� Repair within Boyd's Comers, W. Branch or Croton Falls Res. LJ Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland r ❑ Joint Review
SITE LOCATION / b I., POA S TM # .75-, �0
OWNER'S NAME ��S 1 �1 ec� n PHONE # a7
MAILING ADDRESS
APPLICANT Cj\ r r) 3a4i Qj % S e
Name & Relationship (i.e., owner, tenant, contractor).
DATE FACILITY TYPE PCHD COMPLAINT #
, y C J
PROPOSED INSTALLER �
J3,3�67 R
1J
ADDRESS a/ C- A4S )a k,l/REGISTRATION /LICENSE-# K
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 260
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
I, as owner, or r ort ent owner agree to the conditions stated on this form
SIGNATURE TITLE DATE �/2
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e." Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditions.
Proposal Approved Proposal Denied
Inspectors Signature & Title
�/
Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
REQUEST FOR FIELD TESTING
All information below must be fully completed prior to any scheduling.
ENGINEER OR FIRM: 5AAq IZ -5F— 'SE6'I-1 G PHONE #:
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
DATE: o
PERSON TO CONTACT: (Ztc (A
❑ NEW CONSTRUCTION ❑ REPAIR PROGRAM ❑ ADDITION PROGRAM
REASON: DEEPS: XPERCS:4., PUMP TEST: ❑
ROAD /STREET - —(Z4
TOWN: TAX MAP #: ,22i:#0 —
SUBDIVISION: LOT #:
OWNER:
NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING
YES NO
❑ Proposed SSTS within the drainage basin of West Branch or Boyds Corner &
.o�eit- ,�nris �eservuira. -__
❑ X. Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
❑ );L-. Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
❑ 1r Proposed SSTS design flow 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. The
Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you
answered�es to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a
mutually suitable time for field testing with the Design Professional 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: 107 TIME:_ 167,WO
COMMENTS: ll �ff /1 //
LD r aS +0 De_ Q U a2 H �/�I -dep I
neU. FOR riri.0 Twunu:wr Environmental Health (845) 278 -6130 Fax(845)278-7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool(845)278 -6014 Fax(845)278 -6648
a
-1`
MEMORY TRANSMISSION REPORT
TIME SEP -14 -2007 03:45PM -
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 763
DATE SEP -14 03:41PM
TO 98326462
DOCUMENT PAGES 005
START TIME SEP -14 03:41PM
END TIME SEP -14 03:45PM
SENT PAGES 005
STATUS OK
FILE NUMBER 763 * ** SUCCESSFUL TX NOT ICE * **
SH ERLITA AMLER, MD. MS. FAAP
Commissioner o1'Heolrh
LORETTA MOL1NARl. RN, N ism
Assocfole C'onsm fssloner oj'Haalrh
ai
DEPARTMENT OF HEALTH
I C3cncVa Road. Brcws[er, New Yorlc 10509
Fix C ®VE12 sxmEy_
ROBERT J- BONG■
Cortnry Fsecarllve
ROBERT MORRIS. PE
Dlreeror f Snvlronme'nta! Health
xa. rages:
(iraclucllag cover sheet)
From- C e' a D. steed
raatnam County Deptzrtrnient of I�ealtla
)C For your inYor mtioin Flease respond
For your review Attached as requested
A-s discussed please call
Notes /Messages 'ice a z" ��.. -I— r % ek
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In the event of difUc -111 ?es please contact this off?ce at
(845) 278-6130, ext. 2261
Environmenml [-lealt6 (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 W1C (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early In[crventionlPrescl�ool (845) 278 -6014 Fax (845) 278 -6648
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Date:
DEPARTMENT OF HEALTH
I Geneva Road, Brewster, New York 10509
FAX COVER SHEET
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
To: AZt c H SA )A ? E 5 e. Fax #: 031-6_!Y62_
From: Gene D. Reed
Putnam County Department of Health
X For your information
For your review
No. Pages:
(including cover sheet)
Please respond
Attached as requested
As discussed _ _ ;._n1ese cal. _ ---
Notes/Messages —Zt e- 14, _Z_ V l� 1Qy�,V_ 4 r wL 45 d•
$4
In the event of transmission/reception difficulties please contact this office at
(845) 278 -6130, ext. 2261
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early InterventioniPreschool (845) 278 -6014 Fax (845) 278 -6648
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