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Home My WebLink About1026DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.47 -2 -17 BOX 11 I m 0 1 1 1 1 a ti, . - �' 1' 1, J hr. ■ ti Al me ti ' 1' a L I. ILT 01026 E' PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use On KJ / Repair Permit issued in last 5 years / Repair within Boyd's Comers, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC - mapped wetland SITE LOCATION J D L OWNER'S NAME �FK C r Trl,, MAILING ADDRESS S-4 m& APPLICANT �- / GI ^d& // . Name & 6%lationship p.e,(owner, tenant, contractor) ft �M7 PERMIT# I) U Not in Watershed ❑ Delegated ❑ Joint Review TM # PHONE # hjj :, ,�J 2 - %JFyy DATE s 2 FACILITY TYPE r-S PCHD COMPLAINT # PROPOSED INSTALLER ►1,�a� i� , s G PHONE #?kr- ADDRESS a0 tr Ere, r^ REGISTRATION /LICENSE # 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) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) septicinstaiter; agree to'compl ith the conditions of•this permit for the septic system-repair SIGNATURE TITLE �. DATE P (installer) Pro osal approved with the fo 'n conditions:' onditi ns: ; 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. iuTCQUei "ar- nul v Proposal Approved Proposal Denied ❑ C--' Z' L Q 9 (.7 A, J D Inspector's Signature & Title Date EWiration 15ate Repair proposal is in compliance with applicable codes. Yes 0 No ffl-' COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 I December, 28, 2009 0 1. 8'8" 2. 14' 3. 23' 1. 14' 2. 15'8" 3. 20'4" Tri pi 380 Haviland Dr Patterson NY ej Tax Map # 25.47 -2 -17 0 Sal concrete septic oi4LL► ses+ric °srarew�s�; — a/nne sass — �XCAYAT�N® •CONTRACTORS 845 - 279 -809 www.ty�rdi /loops /� mom i PUTNAM COUNTY HEALTH DEPARTMENT .. DIVISION OF ENVIRONMENTAL HEALTH SERVICES NQ Internal Use Only PERMIT #� ILI ❑/ Repair Permit issued in last 5 years ❑ pot in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. PieDelegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION U&) AA �r' TOWN s TM # OWNER'S NAME PHONE # Z7R 799U MAILING ADDRESS -SA, APPLICANT Name & Rel 'onship (i.e., o er, tenant, contractor) DATE PCHD COMPLAINT # I 1 b FACILITY TYPE Yt.S, PROPOSED INSTALLER --rL4 HONE # 27?R�6 ADDRESS AEGISTRATION /LICENSE # /0.5_9 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 eegent of the re 117_. t � -L ( 1 S t "41ir� .k"s ,.Jl'll� L: i / ?,7 n ne✓,�,� `1��L -� I, as owner,agree to, the conditions stated on this form -10 SIGNATURE -� �A � TITLE d ci,,il Act DATE Lal' f-1,16 (owner) I - ` I- the, septic'irtstailer; agiree- to'6omply withythe'conditions*of tWi 'permiffor the se`pfic system repair SIGNATURE (installer) TITLE DATE 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 Pr sal Approved Proposal Denied ❑ Ig 161-7110 ��._ 7eDai ctor's Signa & itle Date Expiration Date w r proposal is in compliance with aDDlicable codes Yes O No W COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUT-NA-'VI COUNTY DEPARTMENT OF HE-UTH DIVISION OF ENNVIRONMIENTAL,HEALTH SERVICES DESIGN DATA S,HLI:-*ET - SUBSURFACE SEWAGE TREATMF-JNT SYSTEM Owner: Address: 29—Q�V,11 Located at (street): TIM# -Section: Block Lot' Municipality: Watershed: SOIL PERCOLATION TEST DATA Witnessed by: Date of Percolation Test: Date of Pre-soaking: 7110 F Hole No. I. Time Run No.. Start Stop Elapse Time (min.). I Depth to water from - ground. surface (inches) Start - Stop Water lev,*61' drop* in inches Percolation Rate - min/inch 1;5-)l 3o I cam - � 75' -.4 5 2 3 4 2 3 4 5 2 3 4 5 No Ees: 1. Tests to be repeattd at same depth until approximately aoual r)e-,colation rates are obtained a. each pe-,coladob test hole. (i.e., < 1 min for 1-30 miniinch. < 2 min miniinch). All data to be submitted for review. tor, Depth measurements to be made from LO W liV.- 41'5 o to 3 _, — - -------- [OW5 OU C- 1 -m Ir 0' Ovv I 3RERLiTA AMLER, MD, MS, FAAP Commissioner of Health LO)!ZETTA.MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH I Geneva. Road, Brewster, New York 10509 REQMST FOR HELD TBSTLNG ROB 3. BONDI Count F Facecvtive ROSEI T MORRIS, PE - -Dkdct�-ofEmiron ental "Health- - - All information below mast be fiffly completed prior to any scheduling. DAI ENGIlVEER OR FI ZN •c, _ PHONE #: PERSON TO CONTACT: 0 NEW CONSTRUCTION 0 REPAIR PROGRAM 0 ADDITION REASON: DEEPS: PERCS: ESC PUMP TEST: 0 � • � wit /Z.`?�.!ilG�� SUBDX' ION: TAX MAP #: LOT#.- YES NO ❑ ❑ Proposed SSTS within the drainage basin of West Branch or Boyds Corner Croton Falls Reservoirs. _.._�..; ._. [3 - Troposed-SSTS within 500 feet of a.reservoir, reservoir- steling ;control lake o D Proposed SSTS within 200 feet of a watercourse or a DEC wetbm.(L ❑ o Proposed SSTS design flow greater than 1000 gallons/day or SPDES Perml ❑ O Proposed SSTS for a Commercial Project 4 le-.,- -0 required. J 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 (3oint.or Delegated) based on a response. If you answered yg to any of the questions, NYCDEP must witness the soil tests.. This Departmentwill 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 d then subsequent infornoation 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 CQUNTY USE ONLY DATE - 7 /,c' T.rnR- �•' 3�/�i"'► COMMENTS- Envirownedd Health (845)27&-6130 Fax(845)278-7921 Water Supply Section (845) 225 -5186 Fax (845) 725 -5418 Nursing Services (845) 278.6558 Fax (845) 278 -6026 WIC (845) 2786678 Nursing Home Care Fax (845) 278 -6085 Early iaterventioNPresc600l (845) 278 -6014 Fax (845) 2784648 L'd 6969-6LZ (969) IIePUAi d£Z :£0 OL 9L Inf M I October 25,:2010 1 22' 2 63' 3 70' 4 78' T 16' i 1 18'6" 2 56'6" 3 64" 4 73' T 15' High Capacity 16" H �w :Y 1 1 Tripi 380 Haviland Dr Patterson NY Tax map # ..................... EXCAVATING CONTRACTORS www.ty n d a l l se pti c.co m (845) 279 -8809 I c,