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HomeMy WebLinkAbout1268DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.70 -1 -27 BOX 12 1 •: �. kc 1. ' .. .. . 1 •: PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES r I.�.�,..,::.......:...:... __ _: ... _..,:�..:.�.:. -: - OPASr,.&.L;-' F�f:t-_ SE-W AGE-TREATME rJT:S`rSTE-QVi-.REPAIR-- --;:-,.��_ Use Only PERMR # dl �) 4 - I / Li M Repair Permit issued in last 5 years LJ Not in Watershed ❑ n Repair within Boyd's Corners, W. Branch or Croton Falls Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a 4watercourse or DEC - mapped wetland ❑ Joint Review SITE`LOCATIONt Su' Ar✓ D To N OWNER'S_NAME p EV ��PHONE =# MAILING_ADDRESS APPLICANT 3-9 IhCS Name & Rel onship (i.e., owner, tenant, contractor) DATE 18�)'Nwf/ FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER 7r9 /gyp s PHONE # ol I ADDRESS % Gst'�cnn ;�� i ��.•i REGISTRATION /LICENSE # a'31 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. �iti Z le d- see -,A sr Ae-e 77z- /3 L. 101k-e, I, as owner,agree to the conditions stated on this form tSIGNATUREA � -- T T (/& LEiA,f{1U9� .(owner), _ r - - "'i;'Yile-se tilc-iilstaflei 'a reE to comply -witli tie wnd4ionB-or,this permit-fo 'tha•se tic -s •stentre fir - __._.� _... __.._..__........_ P�- 9' P Y P F5` Y P SIGNATURE TITLE 69(1 J DATE (installer) Proposal aapr d 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 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 Pro osal Approved Proposal Denied ❑ /U // ii Inspector's Sigifature & Title : Date Expiration Date i Repair proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML fC;..Cid ,d,6n Z Rev. 2/07 C L.s✓ {k� k iy.e °�ydY� t d ti, s iJ # f +y`r . T. .. S rr> y+�r� fix* __ - gip.. C a7maD �• 00 ., � ©m ©-- o00Gcm ozpS C?�4 = <^ -�-� Go o cio G t. u b�Y k eYY WIP� '`"'4 �'� �1 .J" "' � C/1 � ���i � _ rm '3V *,�.�ty �•��x''1.4d t 1 4 + F .^k is o p .,. a �,.; cb 2 z roc^. b•.. � - � pit.- w c,k V�.•. v � :. .s , ffa.is , � • z>: -. ,. � oo m � Oo Jo° ' �- Gi�oc+ a � - y'+i i i is + zr (pp ry)IV�s t 3f 4qLA k / "SION, ' - .. _'' � ^� ,�:,,. _fir � r F�r- :N']]y4r'.� CIL its u. k7i. Irp. is Ep.41UPM "z. Im L i a xG•9�y -'� tl ,' f p._ I ; hie, r 9 y f a sr3 rp 9 r9' 2w dam' n 1 MAE 1 tti is •.� Q �: x'_01 � 1 +' ��� �! i 1 • r 9 Y :�: t ;ti iPltr �• �P P Nor Ire r i 1 , n , J t �• FF J ,�,�i+ '` 1... ter •4. ION .r ,1 St' P:<. -y � :. i1S 'Gc 1 f.. . � '• J ,� " a y a er,Fi• ��`� � Jd. � .r� :ry,�wc'� _ J.��•-l1 1 1 � ,Jii1�tP ''j :W, I . _ I _. _ 4+y J , •. .1 Imo! L _ �.. -- _ . _ _.f - i.�T yl bl.h �. RN•+ may.! �+.1 I�+• " _ 1' 1 •x�iti.r'n.I C... 1 I '� -.- �' Lam` • `a:. �� � ��• � ;2i� F..j .2 a .J_rr.li''I. •r70�ii1 %•^r•:} -,. ,7� °', Ld ..rt_ —mJ -� _ 3.rL«� L �G- IY��� I_.a.� ..:4 � �,;�. t1 ,. •r J.�•-r.+fi;,"G _I3'p�I ri � uC�a. � �I ' -t _ y ��i ��� � ,��-�� I`I17�•� r 4 �� I `i �i pr -�� o pp Is I I ,.� � J -_ � •'>sl 1 F ; .- t � � , r- �J ,- w �..� ��" ^,�� _; '7E� I"�C' I 4t� �--' s>�G�' 6.. � a � � ' � •nj�' t- ry1..'Yrq� r '.,• 4�1 •�f8 �� t ( LA _� Y, I. -3 ! ICS.. °'�' �_- iC � •• ,� � I, _. ,�' Y��� 71 � f� P - Pi• =.ro-rr - I T �... f ' (_C; •411 tix x N �j•^ R 1} sly 1 �F.. _ W &�]. •� �.^ t 11 �J R :iA_,_ tll I a - @II i Y y ti 3c'4 , : a ' u '.111 .I•.'.f, f.' � i� .. .•.ail - _ • 4r r�•I.: S- a _ I - � -11 � •t_r; -fir , ...0 .. ria 3, 7-ilhm 7- e .r' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: nn '7� f -� r/ Located at (street): ,Svr�i�s�, ��- TM # Section Block _ Lot Municipality: t1 t7�'- -t�"� Watershed: SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: i /�`,' Date of Percolation Test: Hole No. Run'No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch w -Jo3 3O 2 V r� Zi v- /� 3d -2p zo% 2 3 41 1, 2, 3, z 3' 4 [Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole, (i.e., < l 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 top of hole. Form DD -97, ps I of'2 s U � G� 7 ��� e, G'_. 1 'Property Details - Image Mate Online Putnam County Image Mate Online Page 1 of 2 Navigation GIS Map Fax Maps ORPS Links Assessment Info Help Log In Residential P gPerty Info Owner /Sales Inventory .Improvements Tax Info Comparables i Municipality of Patterson, Town of SWIS: 372400 Tax ID: 25.70 -1 -27 Structure Building Style: Ranch Number of Baths: 2 (Full) Number of Bedrooms: 3 Number of Kitchens: 1 Number of Fireplaces:: 1 Overall Condition: Good Overall Grade: Average Porch -Type :._._..... Porch Area: Year Built: 1967 Basement Type: Full Basement Garage Cap.: 2 Attached Garage Cap.: 0 sq. ft. Area Living Area: 1,570 sq. ft. First Story Area: 1,570 sq. ft. Second Story Area: 0 sq. ft. Half Story Area: 0 sq. ft. Additional Story Area: 0 sq. ft. Three - Quarter Story Area: 0 sq. ft. Finished Basement: 0 sq. ft. Number of Stories: 1 ..�� �•E .�� . ..�- .. X11m.e Photographs No Photo Available t i y � a y kf a. i a .. 4 p �,r,. �_ �"�yT'•N nom, _ � � .4 �r•y� —� . ^�41'�k �4+ t � � l�u( tr % W � 1' a t e F � "Y1 7 T _ F iP ys`i N' �'d 'q ^E 5'�r'i �S h f, •.. ty NI r t. t i y � a y kf a. i a .. 4 p �,r,. �_ �"�yT'•N nom, _ � � .4 �r•y� —� . ^�41'�k �4+ t � � l�u( tr % W � 1' a t e F � "Y1 7 T _ F iP ys`i N' �'d 'q ^E 5'�r'i �S h f, •.. ty Property Details - Image Mate Online Page 1 of 1 T . .. Putnam 'County - -- Image Mete Online Navigation GIS Map Tax Maps I ORPS Links Assessment Info Help Log Ir Residential Property, Info _ Tax Info Report Comparables Municipality of Patterson, Town of SWIS: 372400 Tax ID: 25.70 -1 -27 Ownership Information Name Address Thomas Van Doran 26 Sullivan Dr Patterson NY 12563 Elizabeth Van Doran 26 Sullivan Dr Patterson NY 12563 Sale Information Sale Date Price Property ..Class.- - Sale ..T� pe Prior Owner 9/27/1993 $163,500 210 - 1 Family Res ' Land & Building Kardauskas, Edmund Value Usable . Arms Length Deed Book Deed Page Yes Yes 1216 8 Photoaraohs No Photo Available Maps View Tax Map Pin Property on GIS Map--- . View in Google Maps View in Yahoo! Maps View in Bing Maps Map Disclaimer il. aspx?swis =3 72400 &print... 10/14/2011 Property Details - Image Mate Online Putnam C o- un t` y- 9mage Mate Online Navigation GIS Map Tax Maps Residential Property Info Owner /sales Inventory -_ _Improv_ements Tax Info Comparablesa Pagel of 2 11 ORPS Links I Assessment Info I Help 'Log In Municipality of Patterson, Town of ISWIS: 1 372400 ITax ID: 1. 25.70 -1 -27 1 Tax Map ID / Property Data Status: Active Roll Section: Taxable Address: 26 Sullivan Dr Property 210- 1 Site 210- 1 Class: Family Res Property Family Res Class: Site: Res 1 In Ag. No District: Zoning Code: RPL10 - Bldg. Style: Ranch Put. Lake Neighborhood: 00536 -` School Brewster District: Legal Property 06200000030060000000 Description: 001000000130000000000 62 -3 -6 2011 - Total Equalization Tentative 100 x 130 100.00% Acreage /Size: Rate: 2010- 100.00% 2011 - 2011 - Land Tentative Total Tentative $23,700 $234,300 Assessment: 2010- Assessment: 2010- $23,700 $241,500 2011 - Full Market Tentative $234,300 Value: 2010- $241,500 Deed Book: 1216 Deed Page: 8 Grid East: Grid North: hs No Photo Available Maps View Tax Map Pin Property on GIS Map View in Google Maps View in Yahoo! Maps View in Bing Maps Map Disclaimer MEMORY TRANSMISSION REPORT FILE NUMBER DATE TO DOCUMENT PAGES START TIME END TIME SENT PAGES STATUS FILE NUMBER TIME OCT= 1'4`20ii - 11:0OAM TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH 736 OCT -14 11:OOAM 82784865 001 OCT -14 11:OOAM OCT -14 11:OOAM 001 OK 736 * ** SUCCESSFUL TX NOT ICE * ** P'2i7C P�!S SA8 8AS PA8 F217C SA7C F7►g WPM= P'.7►S PZLW wam RECORDS MZa7.17AC�7ffiT . sD r»rs caoa>vrr�c RscoRns c�rrsR aa.a MxcROC•�apaxcs Ban.,�bQ - from the AEIIP3►12T!®7'r (�� TO s Reco�as M= - = gemaat Pexsoa Reg�seat - X.Cr ct23TXONw • •. �• -f3 % l p•- Cotmzaercial Addit3.oa /Repair Realty subcivisioa Ac�built otber Name a O7r owsser (if -e) /giasl Sava3.1a3b1 street s �S c.� o.?�� /L� ✓a-�L n Jam_ .L�1� Town •�cTTea- SO-� -i Tax Ot%er Sdexltifyiag Sxiformatioa s Site=-L=&3. =astruGtioae e - 3MCeaivecl bye pate Par$oa 12 ®ce v agr Pi e. REC`ORDJS rM =039 4ZKD7LY 8rocessad by s Date s Returned. to R ab c3 s _.- RMH 2sg (6/99) F.31eci- Dates, M DEPARTMENT OF HEALTH Division of Environmental Health Services CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A-WATER WELL PCHD PERMIT WELL LOCATION Street Address Town/Village/City Tax Grid Number WELL OWNER N' e / � aV�i( Mailing - � A ct Address 4 1 Yo &o2 j OPrivate O Pub lic USE OF WELL 1 - primary 2 - secondary 13 RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP 0 FARM 0 TEST /OBSERVATION O INSTITUTIONAL 0 STAND -BY O ABANDONED 0 OTHER (specify AMOUNT .OF USE YIELD SOUGHT_ gpm /# PEOPLE SERVED /EST. OF DAILY USAGE C5_0Z) gal REASON FOR DRILLING ONEW SUPPLY ❑REPLACE EXISTING SUPPLY []PROVIDE ADDITIONAL SUPPLY DEEPENs'EXISTING WELL O TEST OBSERVATION DETAILED REASON FOR DRILLING , - i t WELL TYPE DRILLED DRIVEN ODUG GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES _K_NO IF WELL IS LOCATED IN 'A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE ' TO *"PROPERTV -"F ROM" NEAREST' WATETF" MAY.N., .........r ..... - .. _ -.... _...._..............._....__.- ....._.._ _ ......_._ ..__........... LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED []ON REAR OF THIS APPLICATION []ON SEPARATE SHEET r (date) (signat e) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant s.hall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County'Health Department attached to this permit. Date Date 3. Submit'a Well-Completion Report on a form provided by the Putnam County Health;Department. of Issue: g 19 ___������ ermit Issuing fic of Expiration: 19� White Permit is Non - Transferrable copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 2/87 __ _ Oranae coDv: Well Driller - -PUT DAM- COLTNr -PY IiFALTH - DEPM-rMR?r , ...... _.. - .._........ _ . _ ; ,. : -I DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. . Deputy Commissioner of Health = FIELD ACTIVITY REPORT - Sheet of INSPECTION NAMED r v `' s _ Orig. Routine _ Orig. Complain ADDRESS Orige Request No. Street Town TM Noe _ Canpliance Complaint Comp MAILING ADDRESS Final P.O. Box Post Office Zip Code — Group Illness Construction TELEPHONE Reinspection PERSON IN CHARGE Field, Sampling Only OR INTERVIEWED Field Conference Name and Title Other DATE e � � TYPE FACILITY TIME ARRIVED TIME LEFT Explain FINDINGS: ezltn - INSPECTOR: Signature and PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: TELEPHONE: a 4. DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 CON'S'T'RU'CT `.A" WATER-WEI;L� PCHD PERMIT # WELL LOCATION Street Address c2 Z 54 LG Z 1 1v R? Town /Village /City Tax A4 F1 1EW60 i,,l Al V 6 Grid Number a —3-6 WELL OWNER Name ,,<4P- b,41)Sk .S A.J Address A9 71-A 0V S OBI -1VA i/ M • Wrivate O Public USE OF WELL 1 - primary 2 - secondary ',RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP ❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑!INDUSTRIAL 0 INSTITUTIONAL ❑ STAND -BY O ABANDONED ❑ OTHER (specify ❑ AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 3r /EST. OF DAILY USAGE � gal REASON FOR DRILLING WNEW SUPPLY REPLACE EXISTING SUPPLY ❑PROVIDE ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR DRILLING -S oci W./ G •F % ., r WELL TYPE 9DRILLED DRIVEN ®DUG ❑ GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN.A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name' VD ,�tp7-,tSiA�/ LcI�Z�� ��i/E�9bAddress: By IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY S_..e. T. �, -T n , -- FROM NEAREST - WATER-- MAI.N..; -..: :... _.,_......... �� vTr,Iti L TO- � RflP �RTY LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION 5QN SEPARATE SHEET Boyd Artesian Well CO., Irt (date) R. D. 5 _ Route 52 (signatu e) GarR4ely N. Y 10512 PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department Date of Date of Permit Issue: .'� 19 �--2• --� �. ___ ___ Expiration 2 19 Permit Issuing Official is Non - Transferrable TITLE: • PtTTNAM OOUL�`1'Y HFALTHF DEPAl2�1ENT' _ DIVISION .OF ENVIRONMWAL HEALTH SERVICES. John M. Simmons, M D Deputy Camniss oner of :Health =FIELD ACTIVITY: °REPORT Sheet of // - INSPECTION ` NAME {' — Orig. Routine f ADDRESS ip.�, �' ®.` - brig. Canpl.ain Orig. Request .No. Street Town TM. No%' _Compliance j -- — Complaint. Comp r MAILING ADDRESS. _ -, Final P: X. Box Post ti0f f ice G Code =Group Illness., Construction TELEPHONE. h Reinspecton ,.w PERSON IN C HARGE / Feld,'.Sam pling Only OR .INTERUIE&VED , . Field Conference tle 1Vame and Ti " Other DATE . TYPE FACILITY 777/11 TIME =ARRIVED TIME LETt Explain .V- FINDINGS � S SRS € �% "2 .G - y�"I(rk"�'. -� �""--',�G✓' "�-•® i - _ i INSPECT'OR: TELEPHONE e t Signature and Trtle- - PEEZSON IN`'CHARGE OR `== INTERVIEhTF:D.° (`. I acknowledge this Field Activity Report SIGNATURE: . TITLE: �-29 -s�y3 ;J o. . J w w Boyd Artesian Well, Co., Inc. -: D -No.- Carmel N.Y. 10512 ( 914) 2 5-3196 v'11<6eYR,/ : ,P _fa.ev � F *'%! S.//1 w D2 SIO/s,b Rel 2.1