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25.57 -1 -5
BOX 11
01155
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SITE LOCATION
OWNER'S NAM
MAILING ADDR
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFECLAL USE ONLY
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PHONE f — .21—,90"
PERSON INTERVIEWED d go �✓' PCHD Complaint #
Name Relationship i.e., owner, tenant, etc.
DATE % I //A lD q
TYPE FACILITY Y'e--!� .
PROPOSED INSTALLER PHONE 2 2q—Prof
ADDRESS REGISTRATION# !,3
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional'engineer or registered architect.
I, as owiier;'or reported agent of ommer agree to -the condition's stated' on this form.
SIGNATURE TITLE
Proposal r v e following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
�L 04 d - 5-
DATE Q
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6 diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
D,&
Febuary 2005
VA
1.44'
1.29'
2.41'6"
2.321
3. 44'
3.371
4.521
4.441
T. 40'
T. 231
13
Papps
238 Lakeshore Dr
Patterson
Tax map#25.57
ex.septic tank
ex. drywell
2
chambers
3 E3
4
T 'd 30 1N3WiNUd30 AiNnoo WUNind : 3WUN
T26L- 8L2-Sb8: -131. LT :LT 03M 9002 -6 -83d
BW�01
Februay 9, 2005
Department of
Environmental
Protection
;:.._ . ...
Mr. Bill Hedges, P.E.
Putnam County Health Department
ven®ne.Ne�Yods ' . ,
1 Geneva Road .
poses �a9s . • .
Brewster, New Yoik 1(1'509
paN id B.ITweetty' ' - • -;.,
Re: Hazel Capps SSTS - . Repa?;.r .of Existing System.
A,ctii%q Comrr�iss :oiler:: t
(T) Patterson; Putnam County .
- g :
East Branch ReserVoir Drainage Basin
PCHD/N. YCDEP Repair Program - Joiat Review
DEP Log # 2005-EB-01 34-RE. 1
Dear Ivlr. Hedges:
$emu of way s�
This letter is to inform you that the Ne xr York .City Department of
Environmental Protection (DEP)!has no objection, to the approval of the above-
_ "' a u �!'D'
pcdniir�s+�bner • .. ' •
referenced se tics steno repair. This determination is based on the. review of
P y P
•
submitted, documents including the drawings titled "Proposal for Sewage
�'��ep4 >' -��. '
Disposal System Repair -• Tax Map# 25.57 -1 -5 — 238 Lake Shore Drive ", dated
12/16/04.
- - Please contact me after the repairs -are-comp leted to schedule a follow -up
inspection. I may be reached at (914)742 - 2055.
:...
Sincerely,
Danny Shedlo, P.E.
Civil Engineer H
Project Review
C m °ErWRt
. M�MI�'
ww.n C, y..Qe, •�,.
- x 9 18 % ' b'E P. - K.E•.� P. .... • .
t0'd
xc: fohn Dunn, P.E., NYSDOH
9Z :9 t 500Z 6 q _I, Eh£0 -OLL •-V L6 :X8A
SITE LOCATION A44it f--ClUre TW 41.01".J 7-. /-0
OWNER'S NA PPHONE; -,'� Y/V -,Z 7 390xp
NAME d-A Z'-'d -)�� 4'7- h <* -9.9 &Abu/
MAILING ADDRETS ------
AA
PERSON INTERVIEWED 19 W./I e-r, PCHD,Cdmplaint #
1 a tiqw hip e owner, i etc
DATE / D TYPE FACILITY V�
,
PROPOSED INSTALLER g;_,.PHONE
ADDRESS REGISTRAT.
Proposal (include sketch 166ithig,all Adjacent wells
--NOTE: Repair must ,
. be, iri siame,161 cati o* n Afid-6fisame type .as ofiginal.sewage dispos'a, l sys
tem .
Diffeidfit location
may req��6�ubinittal'Q f proposal from licensed prof 6isional engineer of registered are hi tect
2.
I, as owner, or reported agent of'o"wne'r aij#6e to the conditions stated on this form.
SIGNATURE TITLE DATE
Pr0 2o al approved with 16 eioilo*ring conditions:
Procurement of any Town pemut, 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 ins I talled"components tied to two fixed points (e.g.,h6use comers).
d. System deschiptio"'(e.g., . 1250 gal. Concrete septic tank, three pFecast�Vdiam. X Gdeep
e. Installers' name and number.
-3. Sy stem repair to be performed in acco rdance With, the'above proposal and'cbfiditions.
P-1
rop s, approve
pedtoi's Signature .&Title N(TE
COPIES: White (PCHD)-, Yellow (Tcw4:Bl); Pink (applicant)
PC-RP 99ML
Department of
Environmental
Protection .
February 9, 2005
Mr. Bill Hedges, P.E.
Putnam County Health Department
1 Geneva Road
Brewster, New York 10509
Re: Hazel Papps SSTS — Repair of Existing System
(T) Patterson, Putnam County
East Branch Reservoir Drainage Basin
PCHD/NYCDEP Repair Program — Joint Review
DEP Log # 2005-EB-01 34-RE. 1
Dear Mr. Hedges:
This letter is to inform you that the New York City Department of
Environmental Protection (DEP) has no objection to the approval of the above -
referenced septic system repair. This determination is based on the review of
submitted documents including the drawings titled "Proposal for Sewage
Disposal System Repair — Tax Map# 25.57 -1 -5 — 238 Lake Shore Drive ", dated
12/16/04.
Please contact me after the repairs are completed to schedule a follow -up
inspection. I may be reached at (914)742 -2055.
Sincerely,
I � Dt,
Danny Shedlo, P.E.
Civil Engineer II
Project Review
xc: John Dunn, P.E., NYSDOH
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