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PUTNAM COUNTY HEALTH DEPARTMENT
'DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS;
,27 5-Y-5 "Y
APPLICANT C14-In (00�,.5
Name & Relationship p.e., owner, tenant, contractor) .
DATE /cam FACILITY TYPE ��5 : PCHD COMPLAINT #
PROPOSED INSTALLER C�� ��n�vr.�,„�,,, PHONE #
ADDRESS 56 �/�'1 �u� r EGISTRATION /LICENSE # Z Z7(/,
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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 Vent of the repair.
I, as owner,agree t conditions stated on this form
SIGNATURE TITLE DATE C1 I l S I U
(owner)
1, the, septic instal , i to comply ditiers of This persrit for the septic system repair
SIGNATURE TITLE DATE �S v
(installer) /
ProRWW aDOroved with:the following 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 perforrned 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 ❑
Z In pelctoes ignature & Title fr Date Expiration Date
I
e ro osal is in co m liance with a licable codes Yes O No M
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
�%5��n
G& M CONSTRUCTION
f'—r C) 175 E. Holmes Road
-,HOLM*ES'-'-NEW YMPW-12'531
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G & M:CONSTRUCTION
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(914) 8784355
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISIOIS', OF ENVIRONiM-Et-N' -T-AL-IfEATLII,-S-E-R VICE-S
FIELh ACTIVITY REPORT
3-f-)o L,/,sf/vc flfl� loc-4c,1016--
Street Town State zip
I PERSON IN CHARGE
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Name and Title
TYPE OF FACILITY :S
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Caswell F. Holloway
Commissioner
cholloway@dep.n'yc.gov
59 -17 Junction Boulevard
Flushing, NY 11373
T: (718) 595 -6565
F: (718) 595 -3525
Bureau of Water Supply
Paul V. Rush, P.E.
Deputy Commissioner
prush @dep.nyc.gov
465 Columbus Avenue
Valhalla, New York
10595 -1336
Tel (914) 742 -2001
Fax (914) 741, -0348
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October 13, 2010
tMi. Joe Paravati, P.E. -.. ' _ _ - ..... -.. -- ... ... _ _ ........ . .
Putnam County Department of Health
1 Geneva Road
Brewster, New York 10509
Re: Young Residence- SSTS, Repair
320 Lake Shore Drive, (T) Patterson
TM # 25.65 -1 -33
East Branch Reservoir Drainage Basin
DEP Log # 2010 -EB -0873- DJS.1
Dear Mr. Paravati:
New York City Environmental Protection (DEP) has determined that the above-
referenced application received by the DEP on October 4, 2010, is complete.
The DEP has no objection to !,the approval of the above - referenced regulated
activity. This determination is based on the review of submitted documents
including the plan titled "Subsurface Sewage Treatment System Plan for Young
Residence, 320 Lake Shore Drive, Town of Patterson, Putnam County, New
York ", prepared by D.C. Engineering, dated August 2; 2010.
Please have the applicant contact David Alderisio at (914) 742 -2010 at least two
days prior to start of construction of the SSTS so that the DEP may inspect and
monitor the installation.
. .. _._.._ ....: , ... ' Sincerely,_ .... , .. _.. ... ...... ...
. _..
I�
Danny Shedlo, P.E.
Civil Engineer III
Wastewater Design Review
c:
Roger Sokol, NYSDOH
Oct 13 2010 10:21 P.01
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Sutton Park —465 aolumbus Avenue
Valhalla, NY 104951
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Casweri F. Noiloway
CbMh?issidner
cholloway @dep.nyc.gov
59 -17 Junction Boulevard
Flushing, NY 11373
T; (71$) 59.5- 6.5.65
F: (718) 595 -3525
Bureau of Water Supply
Paul v. Rush, P.E.
- Deputy Cominlssloner
prushCdep.nye.9ov
... _ a85- Columbus, Avenue
Valhalla, New York
10595 -1336
Tel -(914)-742-'2001'
FM.(914)741 -0348 ,_
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Oct 13 2010 10:21 P.02
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Mr. Joe Paravati, P.E.
Putnam County Department of Health
1 Geneva Road
Brewster, New. York 10509
Re: Young Residence- SSTS'Repair
320 Lake Shore Dive, (T) Patterson
TM # 25.65-1 -33
East Branch Reservoir Drainage Basin
DEP Log # 2010 -EB -0873- DJS.1
Dear'Mr, Paravati:
Octobff.13; 2010 _ . _..... __._:...__.....
New York City. Environmental'.Protection (DEP) has determined that the above-
; referenced application received by the DEP on October. 4, 2010, is complete.
The DEP has no objection to !the approval of the above - referenced regulated
activity. This determination is based on the review of submitted documents
including the plan. titled "Subsurface Sewage Treatment System Plan for Young .
Residence, 320 Lake Shore Drive, Town of Patterson, Putnam County, -New
York", prepared by D.C. E- lgineex ing, dated August 2, 2010.
Please have the applicant contact David Alderisio at (914) 742 -2010 at least two
days prior to start of construction of the SSTS so that the DEP may inspect and
monitor the installation.
c: Roger Sokol, NYSI)OH
Sincerely,
Danny Shedlo, P.E.
Civil Engineer M
Wastewater Design Review
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
' I
.LORETCA,MOLINARI, RN, MSN
Associate Commissionerof Health
ROBERT J. BONDI
Conw Execid oe
ROBERT MORRIS, PE
Director of Ewironmental Reafth
DEPARTMENT OF HEALTH
1 Geneva Road„ Brewster, New York 10509
REQUEST FOR FIELD TESTING
AH information below ;must be fully completed prior to any scheduling DA V ho
ENGINEER OR FEMe-1-1 ul'o Ild PHONE #: zi q
PERSON TO CONTACT: 1C1' ;,l i, q f_r/ - - - - ax)
0 NEW CONSTRUCn' ON ❑ REPAIR PROGRAM 0 ADDITION PROGRAM
REASON: DEEPS: 4 PLRCS:Z"'�UNP TEST: ❑
ROA DISTREET: � a O , a rG I r oc-f-h a vyt
TOWN • ��-i -Y �, TAX MAP #. �' [o s" j- 3 � d 3 }
SUBDIVISION: LOT #:
YES ( ES \�1 N I .
i ADO
❑ n Proposed SSTS wstitin the drainage basin of West Branch or Boyds Corner &
CrotonFalls Reservoirs.
[7 O. Proposed SSTS within, 500 feet of a reservoir, reservoir stem or control. lake. .
o ❑ Proposed SSTS within 200 feet of a watercourse or a DEC'wetland. .- .
❑ ❑ Proposed SSTS design flow greater than 1000 ga.Uonslday or SPDES Permit required
0 ❑ Proposed SSTS for a Commercial Project'
i
It is the responsibility of the design professional to provide the above information prior to soil testing. The
Department will 66rmine the NYCDEP project statu's (Joint or Delegated) based on the response. If you
answered yes to any of the questions, NYCDEP must witness the soil tests.. This Department will coordinate a
mutually suitable twee 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 WM be the sole responsibility of the
design professional to schedule re- witnessing of the soil testing with NYCDEP.
F COUN USE ONLY
DATE: � ' �id 'TIME:
COMMENTS:
REQ. MRFIELD TEffMrSKLY Environmental Health (845) 278-6130 Fax(945)2784921
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) 2784085
Early Intervention/Preschool (845j 278 -6014 Fax(845)278-6648
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• PUTNAM COUNTY HEALTH DEPARTMENT '
j.,�IJNISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
All nformatlon.below must be fully completed prior to any scheduling
SITE LOCATION Gt ns1weA' TOWN ' ! G`f +�'"` TM #
PHONE # .S"'13 �f
OWNER'S NAME ' ' r�� ''7�1'
MAILING ADDRESS r.
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PROPOSED CONTRACTORIINSTAE_LER PHONE # -8Ld I
ADDRESS 24 � . ml- lw�44-s,T-r- IVY REGISTRATION /INCENSE # _-
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ftalM for exploration:- j
O fadlure to surface 10 back-up in house El find limits of system for repair 0 other (explain below)
FOR COUNTY USE ONLY
Ab
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ROBERT J. BOND[
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ROBERT MORRIS,'PE
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Urgent- '`ori koview Please 'Comment 7 Pie--se Repi,y ZP[ease Recycie
In the eventoF,t-ziis-,nission/-eception difficuffies., piease contact the Environmental Eleafth
FEH.-;l offlc.- aui`84-1`8-6130, Thank vou.
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MEMORY TRANSMISSION REPORT
FILE NUMBER
DATE
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START TIME
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LOAM�(CID) SOILS AS PER
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C O' 1500 GAL. COMBO TANK.
1 a�x 1 REFER TO DETAIL W
C.O. cn c 4' PVC SDR -35 SEWER LINE
co
® 2X W/ CLEAN OUT TIE
INTO EX. LINE i
j EX. SEPTIC TANK TO BE PUMPED
BY A NYSDEC LICENSED PUMPER
AND BROKEN UP FOR FILL
4185.26'
NOTE:
ALL COMPONENTS AND /OR SOIL FROM THE
EXISTING SSTS ARE TO EITHER BE BURIED ON SITE
OR REMOVED FROM THE SITE BY A NYSDEC
PERMITTED WASTE HAULER. ALL REMOVED
COMPONENTS SHALL BE REPLACED WITH SUITABLE
4RTMENTAPPROVAL FU�TO/�/ R.O.B. FILL CONTAINING LITTLE OR NO FINES AND
THEN COMPACTED.
ALTH
SERVICES.
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