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BOX 18
02014
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
�i
�. :.. - i.v - •-- -_....
FOR -SEWAGE TREATMENT SYSTEM REPAIR.--
Internal Use Only PERMIT # K -C&
O Q Repair Permit issued in last 5 years U Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. [J Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland L Jo1M Review_
SITE LOCATION
OWNER'S NAME C
MAILING ADDRESS -�ff
APPLICANT
TOWN ffi l� a&b_P /& „ TM #
,- PHONE #fig
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER -- � ,C.F�� PHONE # &T --Z` - �06g1
ADDRESS Csr<2`— REGISTRATION /LICENSE # /C>(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
I, as owner,agree to the conditions stated on this form
`e SIGNATURES TITLE tt�. DATE
(owner)
- - - -- F,- the -septic installer,-agree-to comply with the- conditions- of this permit for-the septic system-repair - - -
SIGNATURE t c i �t� - - TITLE DATE S7- /E, • 2,611
(Installer)
Proposal approved 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.
l:rll 4;1k,TJI L-14e IAi
Proposal Approved Er Proposal Denied ❑
� z r j//,;L , i
k pector's Signature & Title Dafte Expiratio Date
Re it proposal is in compliance with applicable codes Yes i3 No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
May 'Lb 'LU1 1 14 4b N. U I
K-
Environmental
Protection New York City Department of Environmental
Protection
SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR
DETERMINATION
Pursuant to the authority granted udder:
„ :Article 11,.0£ the ,New Xozl� State Public Health Law; Rules and Regulaf�vns F6 .'T
Protection From Contamination, Degradation and Pollution Of The New York City Watet
Supply and Its Sources, 15 RCNX Section 18 -38 (or Chapter 18); and 10 NXCRR
Appendix 75 -A Wastewater Treatment Standards - Individual Household Systems;
Putnam County Septic Repair Program Plan — March 2005.
DEP Project# Ta 1¢ PCBP.Repaiur# ~ Q�o7 — I
Site Location: l L17 T.M.#
Reason for Joint Review:
Drainage Basin 200' of WC/Wetland_� Repeat Repair in 5 Yrs.
'Name of Owner:
Owner's Address: 13-7 Jou-k. Lk, Awve f evf°�,.
Drainage Basin of'Project Site:`
Installer: o
General Description of Sewage System Repair: ,s4 /I Ae w .f
1/0 C u C7
Dates of Site Inspections and Soils Tests:
'Approved' *Incomplete Delegated "Denied_
*Required: Soils Tests Repair Sketch . WC/Wetlands Wells - Other.
*''Reas
Detemination made by:
...... 2
Engineering Division Date
SHERLITA AMLER, MD, MS, FAAP
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
TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
'' -DAAW Y S R c% t- o
PRIORITY - SEPTIC REPAIR
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
JOINT REVIEW '�,�t 7E-F--C,>
PROJECT: /3 :7 'SouT 4 D`iZ;
TOWN: ��¢rT, 7Z� oh/ SUB'D APP DATE _A/
NOTICE OF COMPLETE APPLICATION:
DATE: 5 �L e1 1//
❑ / Within the drainage basins of West Branch, Boyds Corner Reservoirs or Croton Falls.
Within 500 feet of a reservoir, reservoir stem or control lake.
Q/ Within 200 feet of a watercourse or a DEC wetland and appearing on a subdivision
map approved after December 31, 1992.
❑ Design flow greater than 1000 gallons /day.
❑ 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 j
a
MEMORY TRANSMISSION REPORT
FILE NUMBER
DATE
TO
DOCUMENT PAGES
START TIME
END TIME
SENT PAGES
STATUS
FILE NUMBER 283
SHERLiTA AMLER, M0. MS. FAAP
Commissfonar of Hca!!h
LO RETTA MOLINARI. RN, lNS1V
,arsoclaio Commtss /over of Health
TIME. 03.:18PM
TEL NUMBER 8452787921 "
NAME ENVIRONMENTAL HEALTH
283
MAY -24 03:16PM
819147730343
006
MAY -24 03:16PM
MAY -24 03:17PM
006
OK
* ** SUCCESSFUL TX NOT ICE * **
d yROSERT J. BONOI
� y- Counry Sxccarive
'��t+ ROBERT MORRIS, PE
W Olrecsor ofEm+[ronmonta! Health
pEPARTiV1E1V�" OF HEALTH
I Geneva Road, Brewster, Tlow York 1 0509
FAX COVER STET
_. Toe �1- ��5zitlil 9 % �� -�l �1�G. f� Fax #: -7 '7 � -- G� 3� ��-•
(includ"tng cover sheet)
Fronn: Gene D_ Reed
/Putnam County Department of I3ealth
✓ For your information ✓ Please respond
For your review Attached ns requested
A.s discussed Please call
Notes /Nfessages
Yn the event of transmission /reception difricuities please contvct this office nt
(845) 278 -6130, ext- 2261
E-irenmental 1•/ealti, (845) 278 -6190 F— (845) 278 -7921
water Supply Section (845) 225 -5186 Fax (845) 225 -54.18
T-4-1.g ServicCS (845) 278 -6558 F— (843) 278 -6036 WIC (845) 276 -6678
Nursing Homa Caro Fax (845) 278 -6085
Early later Ution/Pr hoof (845) 278 -6014 Fa-< (845) 278 -6648
MAY -9 -2011 12:30 FROM:BOTTGE INC 8452792872 T0:2787921 P.2
P�
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
e
RROFOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE
All information below must be fully completed prier to any scheduling
SITE LOCATION TOWN A�7X�u"dnl TM 7- Z
OWNER'S NAME PHONE # = L- `/'�i -3227
1+ r � y� r
MAILING ADDRESS fu
PROPOSED CONTRACTOR /INSTALLER r " PHONE #.&V-771. &Qgg
ADDRESS ' REGISTRATION /LICENSE # /0107
Reason for eyglorfition:
17.7 failure to surface ❑ back-up in house Ii -find limits of system for repair &vlher (explain below)
& Title
Appointment Date:
kly:excel:septic
FOR COUNTY USE ONLY
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Time
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Data
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PUTIN"ANI COUNTY DEPARTMENT OF HEALTH
DMSION OF ENI-VIRON-IMENT.Al HEALTH SERVICES
DESIGN DATA SKEET -'SUBSURFACE SEW .A.GE TREATiVIENINT SYSTEM
Owner-: 'A'Z440 Address: /37 LAJ<,5
S H,97Z r
361391 A?.
Located at (street", TM " Section: 8(ock Lot
Municipality: I—A-11�7—r'55Z-5-02.2lz Watershed:• �A-57— 25� ,C-AJ
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre-soaking: 0 Date of Percolation Test:. :E;7X-10,ely
Hole No,
Rub NN o.
Time
Start-
-S top
Elapse
Time
(min.)
Depth to
water from
around
surface
(inches)
Start - 8 toj�
I Water
level drop
in inches
i
Percolation
Rate
min/inch
-
3
;2-3
I 3 7
1 4 1//";Le
- M�5-51
X0 -'g- 3
1 :3
L
3
4
5-
F--
F--
2
3
4
2
3
4
I -1c7:Z ro n,- .r.- ;ir 3p, - p n,- -I rh j jr,. r: I q
u: w' +`•. :i:.M.....:...ru:......nw iu...... u.. ro4:•: rr,. 4s: 4?•. u: ii1:: uli. CeY »r.�ivN'w.:1:�i+Yi.+'w'.l`W: ( W�.' uvYii' ru4.' rW:! WV1 L4Af�Y.: �: 1Gf. io: Yr: nvailYl iL' 1YiNa+ wt i.' K1L�1vJ w:. w: Vi.' uiu.. nua�w.: Ya :iiunYS- :.ut�:ivNw.tti:x.r:.wrvn i..:...:• t. 1n. w.:.,. e....... r�tiaura ::..L.�..u�..rnJ�.�...::.::�1 w.�..- A.:..,vr:aW1:J rl.:A':, i
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE = HOLE
M HGL- rOL- T
C r rr�L =
0.3
,r
1.V
2.0' . 0' O
Z.:
3.5'
a J
tow
e- 6omp4Lrj
5.5 I 4e— 5R
e. , d'
7.0'
i.J
.. hi• .� �._ -. �. ....�. -. -. .. .. .......... s .._ .. ._...� ate+. .. t.._ ._ ... �� -.. s .... � - -..r -�. .. - - a ..�. .. n ..-... _.. -. ... - _._ -..,
Q
10.0'
L*tdicate !e�ie! 3t W:E'llC:l �-oL:!dwater is encou:�t�rea �Jo��
I:_dicate level at w-:,-ic`, mottlir__ S observed
Indicate to wl lca water tevef uses aTer being encountered
Deers hole observations r,-,ad-p- by: /�, �� Date 5-11 o
Desi�'--? Professional tia«Le:
Addr -ss:
�icpat'!"_:
It r,
r.'
PUTNAM•COUNTY HEALTH. DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM FIEF AJR
XEJ Internal Use Only PER74111T # 4,1
❑ r' Repair Permit issued in last 5 years ❑ Not in Watershed
U l� Repair within E oyd's Comers, W. Branch. or Croton Falls Res. ❑ .
f D @I6gated
,
LJ ❑ Repair within 200 ft. of a watercourse or DEC- mapped wetland ; r Joint Review
SITE LOCATION~ r `'i` <<. // 4t_ TOWN (t' ?;tit`.'` TIVi
OWNER'S NAME J ii> : 4 t r'i',' ?a r" -h.t PHONE # A f
MAILING ADDRESS 'J
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE ". i f� ,?i ; FACILITY TYPE %t' PCHD COMPLAINT #
PROPOSED INSTALLER PHONE # )'r Z. 7'i" 6c�6'`1
ADDRESS f,:,.:,r { •`)r REGISTRATION /LICENSE #
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. "
' ..�. ii' �C.(� i; l ,!� � r .J'"Y ��if..'4:: /� '�.'..c'f •�_i9"j �f}r %•;� is "i � !� 7',�(. i .•�'. -%t' '1' ....
._....�..` \; , (> , -i .it.lr /, �;;+.._ J�t w'`r% '/ �Pf(`', t.z• p yyt t ,
I, as bwner,agree to the conditions stated'o -n this'f R -
SIGNATURE,,:`,:, t't '`r ;�) , i v� ; TITLE _u.c� ! t: .. iDA7F _.``.r ._ __ w.•_ ...
I, the septic installer, agree to comply with the conditions of this permit for the septic system. repair
TITLE
SIGNATURE
R Z_ DATE ;' • '' _-
t..
(Installer)
Pr000sal rwproved with the following conditions:
1. Procurement of any Town Permit, if applicable..
2. Submission of ar, t uitt repair sketch by than saptbc s;storn irstaiier within 30 days of the repair, in dup?iurte sho,%'in -: .
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 tho duration at which the
completed SSTS repair will function.
5. No completed worIk is to be'backfilled until authorization to do so has b®en obtained from theb6partrribrit. '
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
INYLHNAL Ube UNLY
Proposal Approved °`` Proposal, b�"ied
❑
-
7
. rs M, `. . ... ..,..r a ...
_Ma.
,• ...
:.
inspector's Signature Titib
r,� �..
R$te1.piration
Date
,
Repair proposal is in compliance with applicable
codes
Yes C1
No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
EE
Sheet [of_�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
N AMF • � [l� D Tel:
ADDRESS: 137 5 z 1-61-lee- BA &P 0*1 ^i y
Street Town State Zip
PERSON IN CHARGE
nR_TNTFR VTF.WFTI: 23x e-le- -;,r— e-, T)atP_ 41*'11 !;7-
Name and Title
TYPE OF FACILITY: .5,5 7 S, �; f
r
,&I
v
Signature and Title
RFPQRT RFS'FTV -En RY• _
I acknowledge receipt of this report: SIGNATURE:
02/96 Title;
V-
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