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Home My WebLink About1313DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.71 -231 BOX 12 ry L. �_ � X0 , lb-id LTUL 01313 0 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL--FOR! SEWAGE TREATMENT—SYSTEM -REPAIR YES Internal Use Only PERMIT # ❑ Repair Permit issued In last 5 years Not in Watershed ❑ . Repair within Boyd's Comers, W. Branch or Croton Falls Res. pelegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland L7 Joint Review SITE LOCATION TOWN TM # .71— –'�I- OWNER'S NAME l.L /17? 1C ! w PHONE # MAILING ADDRESS ` APPLICANT ,C 1Iy, N me & Relationship (i.e., owner, tenant, contractor) DATE �� o�,�.i ,3 FACILITY TYPE t,,fi ell " ?CHD COMPLAINT- # PROPOSED INSTALL R � a PHONE # �y ' h1`' h1p L2 ADDRESS ��,ei/�;�� iG/ REGISTRATION /LICENSE # Proposal (includie a`sepa9te sltch 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. ALL= 2: -/- 110 inn f-� �f I-� iu ✓S `{vf�i..( a �iX.:CfZ�'►a /t °Ch c9 �G.!(c�r.� /.7��- 514`� )c'/�7c ��.� ' i^e!'39Gar'v► I, as owner,agree to the conditions stated on this form SIGNATURE I 24 Ae tJ O Ls TITLE te,, DATE ,�J, I (owner) - - t, the septic installer; -agree to comply with-the conditions -01"this permit for the septic system repair ~ ° SIGNATURE , d= TITLE _ DATE (installer) Proposal approved with the followi g 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. App INTERNAL USE ONLY Proposal Denied /J� Title is in comoliance with aDplicable codes COPIES: PCHD; Owner; Installer PC -RP 99ML El D Da e Yes & Expiration Date ❑ No 012/ Rev. 2/07 CITY t° t % A '�MFiv rA� '�l!1 Jun 10 2010 14: 44 P. 01 New York City a Department nA Mai Protect' RFACE SEWAGE TREATMENT SYSTEM REPAIR DETERMINATION Pursuant to the authority granted under: Article 1 I of the New York State Public Health Law; Rules and Regulations For The Protectioa From Contamination, Degradation and Pollution Of The New York City Water Supply and Its Sources, 15 RCl` Y Section 18 -38 (or Chapter I8); and 10 NYCRR Append x 75 -,A.. Wastewater Treatment Standards - Individual Household Systems; Putnam County Septic Repair Program Plan — March 2005. D EP.Project# /rT PCHID Repalr# Site Location: a T.M.# ? f- -71 _ .......... Reason for __- - Drainage F Dame of 0. Drainage Installer: General 1 Dates of Site _ . Approved Review: 200' of WC/Wetlanai_ Repeat Repair in S Yrs. �,U'iPrn of Project Sate: 4on of Sewage System Repair: �"'�` � � �� d`( I's r f 1 *Required: Soils] Tests * *Reason ons and Soils Tests: '? / *IncompletE Delegated "Denied Repair Sketch WC/Wetlands Wells Other. - _ Dete ion ade by: . engineering DivIston Date g //0 //0 PUTINAINI COUNTY DEP-ARTINIENT OF HE-ALTH DIVISION OF E,,N-VIRONMENT-�.,I-.TE,4LTH SERVICES DESIGN DATA SKEET - SUDSUR.FA(--`E -SE�'AGhTFEATMENT SYSTEM Owner: Address: t-e-kr—sA-rc�- Dnvc- Located at (street): Vk'i4ec- TM M" Section:, Block. Lot Municipality Watershed: SOIL PER'C"OLATION TEST DAT-A Date bf Pre - soaking: -7 li Witnessed by: , Date ol'Percolation Test: A-014- 1 Hole No. Run No. Ru Time I. 'tart - & Stop Elapse Time (min.) Depth to water from surface (inches) Start - Stop Water Percolation level drop Rate in inches min/inch 3 c)(o — -21 1 2 1 Ij 31- X113-71 � 6U - c;2 j i. 3 - ------ -- 1 .4 11g7- 11:531 1 2 3 4 2 3 4 ,Notes: i Tests to be' repeated at same depth and apprommatel-Y- equal -oe-,colation rates are. -rin for 3 min:' obtained a, each percolation tesy hole. EA.. < 1 0 Anch, < = min for -of: miniinch i. Ail data to be submitted for review. -its to im ofhoie. Depth m.asurtme. e made from tor. 3 ,Notes: i Tests to be' repeated at same depth and apprommatel-Y- equal -oe-,colation rates are. -rin for 3 min:' obtained a, each percolation tesy hole. EA.. < 1 0 Anch, < = min for -of: miniinch i. Ail data to be submitted for review. -its to im ofhoie. Depth m.asurtme. e made from tor. 0 SHERLITA AMLER, MD, MS, FAAP [:----n- - :Commissioner of Health - — ... LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ' ROBERT MORRIS, PE Director of Environmental Health F ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM JOINT REVIEW PROJECT: t��y TOWN ": SUB'D APP DATE ,ul0— - NOTICE OF COMPLETE APPLICATION: DATE: r L '3 ❑ Within the drainage basins of West Branch, Boyds Corner Reservoirs or Croton Falls. ❑ Within 500 feet of a rese reservoir stem or control take. Within 200 feet o a watercou a DEC wetland and appearing on a subdivision map approved after ecember 31, 19 Design flow greater than 1000 gallons /day.. t ❑ Commercial SSTS. jtreviewrepair 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 MEMORY TRANSMISSION REPORT FILE NUMBER DATE TO DOCUMENT PAGES START TIME END TIME SENT PAGES STATUS FILE NUMBER 224 224 MAY -28 12:50PM 819147730343 004 MAY -28 12:50PM MAY -28 12:51PM 004 OK SH ERLITA AML.ER. MU, MS. FAAP Comm/sslunrr gf Hso /th LORETTA MOL1114AR1. RN, ms,-4 Assoclolr Commisslonpr gf Merpllh TO: T I ME _ - -- MAY -28 -2010 -:12.: 51 PM TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH * ** SUCCESSFUL TX NOT ICE * ** p, �,q ROfiERT J- 80N�1 �c County Fxacwtva �f ROBERT MORRIS, P6 Oirsccor gf EnvlronmantaL MeoLth 0EPARTMENT CO HEALTH 1 Geneva Road. Brewster. New Vork 1 0509 ENGINEERING ANb DESIGN R'E'VIEW _- PRIORITY - SEPTIC REPAIR - riIEI- .ELATION STATUS FOR • SUBSURFACE SEWAGE TREATMENT SYSTEM PY20GRAM J02'N RE VIE W PROJECT- �V'l� -e �- S TOWS ": ��'-- SUB'D APP DATE /�/�69' —• NOTICE OF COIvLPLETE APPLICATION: DATE- -� +� ��+� /�� O Within the drainage basins of West $ranch. Boyds Corner Reservoirs or Croton Falls. Within 500 feet of a res I voir stem or, control lake. Within 300 feat o! watarco a DEC wetland and appearing on a subdivision map approved aft- r _ e_- ._r._be. 31 4 -� PL/ i Ci Design flow greater than 1000 gallons /day. O Con-imercial SSTS. J treyleWTep ai v Environmental 14eafnh (815) 278 -61 ao F2 (9-43) 278 -742 W.— Supply Secdon (8.15) 223 -5186 Fai (845) 225 -5418 Nursing Serrfees (845) 278 -6558 Fe_.e (8.15) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fc (845) 278 -6085 Early L.co+- .•Dodo., /i�reschoo( (8.15) 278 -6014 P— (845) 278 -6648 SHERLIITA AMLER, MD, MS, FAAP Commissioner of Heafth I _ L )RlET1CA MOLINARII, RN, MSN ,4ssociateCommissionerr pfHe'atih- DEPARTMENT 01ii HEALTH 1 Geneva Load, Brewster, New York 10504 RE SST FOR WLB TESTING Ail information Mow must be fully completed prior to any scheduling. ENGINEER OR PERSON TO CONTACT: ROBERTS. BONDl Caunty Fxecrrtbe ROBERT MOIRR tS, FE ' `Dir'ecctor of Errvironmenurl Dealt. ❑ NEW CONSTRUCnON El REPAIR PROGRAM ❑ AID}LDMCDN PROGRAM REASON: DEEPS: PERCS: ".UW TEST: ❑ 080 suBD VISION: TAX MAP #: NyCDEP ClaTER A FOR JOINT REVIEW ARD WrrNESSING OF SOIL TESTING YES NO 0 0 Proposed SSTS within the drainage basin of West3ranch or Boyds Comer & Croton Palls Reservoirs. .._ -..: _ -. _. _ �.......... .... Proposed SSTS wathiu 500 -feet - 0 0' Proposed SSTS within 200 feet of a watercourse or a DEC wetland. 0 0 Proposed SSTS design flow greater than 1000 gallons/day or SPDES ]Permit required. 0 0 Proposed SSTS for a Comnmerciol Project It is the responsibility of the design professional to provide the above information prior to soil testing. Thi Department will determine the NYCDEP project status (Jgint or Delegated) based on the response. If yol answered ves to any of the questions, NYCIDEP must witness the soil tests. This Department will coordinate 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 there subsequen information indicates NYCDEIP is required to witness the soil tests, it will be the sole responsibility of thi design professional to schedule re- witnessing of the soil testing with NYCIlDE]P. FO COUNTY USE ONLY COMMENTS: Q'�L-4 Eeanraimmeniat Kealth (945)27&6130 Fax(845)278-7921 'Wratw Supply Section (845) 225 -5186 Fax (845) 225 -5418 Neirsing Sen ices (845) 2784558 Fax (&15) 278 -6026 WIC (845) 278 -6678 Nursing Rome (;are Fax (845) 278.6085 Early laterden�ionffl resdml (845) 278 -6014 Fax (845) 278 -6648 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH • - -- -DIVISION OF EN VIRONMENTAL Ii- EATLII SERVICES•-' FIELD ACTIVITY REPORT NAME, AT) RF..gq Street Town State 4 Zip PERSON IN CHARGE E/ 7 l o OR TNTF.RVTFMMT). a Name and Title TYPE OF FACILITY: S ', 5 -rS lZf 7,41F FINDINGS: 35 f4 cv S I /Z.7 y 3� Signature and Title REPORT RF('F.TVFD BY: I acknowledge receipt of this report: SIGNATURE: 02/96 4 ^-- - --••_ _.�.. -.__._ ............ _._..- ........V.._- ._....._.... _.....ter'.... /'•.. sLer, v1 � �.. Ora< -�,+� ile- -e-btiW ` x.41 ►� S' I j �o (' lei, 3o _ bd- 44ip A-w a O.-go Le Mat t n m v1 � �.. Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF'ENVIRONNIENTAL HEATLH SERVICES FIELD ACTIVITY REPORT NiAMi-F:- a, P-k54 in 5 11�ke shire (j�� ✓e. AT)T)1ZF.�S;.� Street. Town State Zip PERSON IN CHARGE yR TT�TTFR VTFT1; O�y' V `�'" Dat Name and Title TYPE OF FACILITY :M;wt$ FINDI4GS: do n t, '� i4 � �-✓� C �e �•t v �� S - tj� S h'�u -1( A