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Home My WebLink About2030DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.40 -1 -32 BOX 18 I I r! JL IN, !�' In IN � .. ' �` j� , f � �� IN r IN L LJ 02030 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..�- .. _- _.,: >.._:....... -..- �zPROPOSAL, FOR =SE- WAGE :TREAT - IENT•SYSTE!!!L- REPAIFi !ES V Internal Use Only. PERMIT # ❑ ICJ Repair Permit issued in last 5 years IJ ❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ 0003i� ' .4 Not in Watershed Delegated Joint Review SITE - LOCATION TOWN TM #-361 yo ~/ OWNER'S NAME PHONE # MAILING ADDRESS APPLICANT 1 44r, _too Tet d,•r i%1 C �n Name & Relationship .e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT•# PROPOSED INSTALLER �, /�o�U & /J, 4 ,J PHONE # ADDRESS �SG�Ies�e', Al s�v,7�1��1/ REGISTRATION /LICENSE # Pr, oWsal (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. /�� ,tlT /� % o %r_c /,%e h�o.•, S�/n2 Tiro 71 I, as owner,agree to theconditions stated on this form SIGNATURE _ TITLE 0111 (°/f�- DATE (owner) - - ~I; -the septic installer; agree to comply with the conditions of-this permit-for the septic= system- repair • SIGNATURE TITLE z evr- DATE (Installer) "'� c Proposal amxoved 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 Proposal Approved Proposal Denied ❑ Inspector' ignature & Title Date Expiradon Date ,Repair proposal is in compliance with applicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2107 L PU.TNAM COUNTY HEALTH DEPARTMENT ff DIVISION"OF ENVIRONMENTAL HEALTH SERVICES ' PFD ®6s ®SA. FOR SEWAGE'TREAT•MP-t " SYSTEM t YE � tr,$errral:Use:OrilY `.P�I�i�i'i ryYt: d J ❑ ❑ Repair Permit issued in Iasi' years FOt.ln lMdterE2e4 LJ '.: ❑ Repair within Boyd s Comers VV Branch or' Croton Falls Res`. Delegated ❑ Bepair within 200 fit of a irrnterctiurse or DEC mapped wetlaoo )oanY Revi@W SITE LOCATION J , /^ TOWN �a L- t�'.rx i` TM # �( :Lfr} t ! v r t Sri �!(t L: .OWNER'S NAME' "'.�•� 'tt`4')/ - :- i('� \ 7a. ? " l 1 PHONE .'. MAILING ADDRESS �, / ; rr.�f, i.lf /i�;, �;. / ` -4W9,9.;`/:':'., APPLICANT Name $Relationship (i.e., owner, tenant, :contractor) . DATP (,,, 210-7-- FACILITY TYPE PCHD COMPLAINT # x-+,91 001 3SED INSTALLER ' �r ,�r � .ai'. PHONE 1' ADDRESS % lr;;; u) i.i c %r; . r�� S. taic�': REGISTRATION /I - ICENSE # T. Proposal (include a separate sketch locating @her house, property lines, all adjacent wells within 200 feet + f-repair and:4he 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. r �G..�..�., C r � %, Ji��J �.�.t.,..r•: �.. 'i ; � �,. '.tis ouiner,agree.ta the conditions stated orb this fo[ -n ;'SIGNATURE r `i' ;_' ( '' TITLE DATt= (%wK` e - --- 1, the septic installer, agree to_comply with the conditions of this permit for the septic system repair rr. �} j, SIGNATURE (ii:'�i I.�'4�c?; .'., `?�"y._._._._ TITLE Y9C.5 DATE C<<' (inrsttaller) / Prr osal apgroyed with the following conditioner j 1. Procuremt3nt of any Town Permit; if applicable. ` 2. Submission of as built repair 5l etc!Kby.the..septi� system installer 1 $b in.3U days.of.the repair, : in .duplicate showin4: . a. Owner's name, Site Street 'Ndme,.T.own and Tai Map number i b Location of installed components tied to two fiiied'poiKtps c: System description (6.g., 1250 gal. Concrete septic tanktc) d. Installers' name'and ptione number. ~` 3. System repair to be perforrhed in accordance with titie above proposal and conditions i 4. The proposed SSTS repair is considered a best'fit design and there `is no 'guarantee to the duration at which the completed 3STS repair will function r�io compietecl twork is to 6a backfifled until ail 4horizrxU in to do .so has been abta,ned from the C}ep rlrnent: . Proposal,Appiob'EC1, :? :Pr��oosaf DRtait?Li ! • .��, lam. �t i %' fJ , °L -.mil r/ t;rrR r'�,,f f Ny'• . Inspector's Watulre & Title !j. A Dat ~' Explra�ilori C3a`e �, Repair proposal is in compliance with applicable_ codes � � Yes O Note' .---- COPIES: PCHD; Owner; Installer i . PC -RP 39ML Rev. 2/07 i RE— 11 oil Vic pay.7 , RA v P Ac Av 'silos? mow T " 13 11A t S SAM. -it two, TOO, KV Ons. I oil 1! Q not v 2 a j*1 •r} Y- . . . . . . . . . . . . . . . . . 7-Y nmw, q, MIA 1 200m-, 77- t Z,3 7s ?. mm—a Kom. nlz W iN," 'P, Not • �E ti I e.. Lam'_ t k� L• � y( r PUTNAM COUNTY HEALTH DEPARTMENT ® L DIVISION OF ENVIRONMENTAL HEALTH SERVICES ... .....:...., . PROPOSALFOR SEWAGE TREATMENT SYSTEM REPAIR , yw. NO Internal Use Only PERMIT # ; ; :' ❑ Repair Permit issued in last 5 years 1 ❑ Not in Watershed ❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ ❑ Repair within Zoo ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION <7%fICZhym holl, . TOWN TM # ( -32, OWNER'S NAME 6,ZW4 A PHONE•# SVQ! • 2,74.2.83',3 MAILING ADDRESS '04/ APPLICANT ��1/d.4 A�fi►�d�l.ti — BG��/Ls� Name & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER Iffig L,uG PHONE # 'Z •&cr6g ADDRESS *9 (W - Etg.�r7� _ REGISTRATION /LICENSE # l001/ 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 reps _ �. C71:��rJ�s7r!S�a %7 /. ►_��7f�f1: A09 4F .- J�-�n�!i�i. ➢��. L ✓�I I, as owner,agree to the conditions stated on this form (SIGNATURE JI�� TITLE Lclit�'C - ... DATE lQ' k17, (owner) _.__._._ i, the- septicinstailer; sgree'to com iy with.the conditions-of this - permit for the, septic system 'repair r SIGNATURE TITLE DATE. (Installer) ProposW aRRroved with the following conditions: 1. Procurement of any Town Permit, H 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 al Approved Proposal Denied El ` / /�- 3 `! Inspector's Signature & Title Date Expiration Date ,Repair proposal is in compliance with applicable codes Yes ❑ No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Putnam County Department of Health Division of Environmental Health Services SSTS Repair — Final Site Inspection Date: /Z . w_ _.Inspected by: Str'eefLocation Town: Repair Permit #: /2 V— -2— 1. Type of System: Conventional ternate l7 Comments TM # 2. Septic Tank Yes No I N/A a. Septic tank size —1,000 ... 1,250... other ..... b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d- nistrihntion Rimy Comments i. All outlets at same elevation (water tested) ... ii. Protected below frost ............................. iii. Minimum 2 & Original soil between box & trenches e. Junction Bog — properly set ............................ f. Trenches i. System: completely opened for inspection ii. Length required ]7_ Length installed iii. Pie slope checked ....................... :.......... iv. Installed according to plan ..................... v. 10 ft. from property line — 20 ft — foundations ... vi. Size of gravel 3/< -1 'h " diameter clean ......... viii. Ends capped .... ............................... g. Pump or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per approved plans b. Fill section — c. Distance from water course /wetlands 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box ......................... . c. Backfill material contains stones <4" diameter ......... d. Curtain drain & standpipes installed according to plan e. Curtain drain outfall protected & dir to exist watercourse f. Footing drains discharge away from SSTS area ......... g. Erosion control provided ............................ Additional Comments: RFSI Rev - 011312 REBECCA WPl'TENBERG, RN, BSN Public Health Director D r-alar of Env&vmneWd Health DEPARTMENT, OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MARYELLEN ODELL County F�aecutive TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW ATTN: o7 n n Y FROM: C c S DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED New Application Renewal 0 PROJECT: e LOCATION:' D,- TOWN: �. �" DATE SUB'D APPROVAL / M/a NOTICE OF COMPLETE APPLICATION DATE: DELEGATED I / i j 9 a Jf �1 f f 4 i i ' a i i ( Pi f i I'll. • (049 d, ! ci A�A��t4 ' E 25 -31 A1V0fa.Ce6AO Ane jrle&,p 'Yo. MY Swrvej ✓oly 19, l965' J 1�62 rry R10454 �?4 11*Ale 717Z-r rlo wlv CPA/ and .r N. e C PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: dJ[ter' G' 1 Address: 3 o Located at (street): % r��o/e n, �, w ('. TM # Section: _ _ Block _ Lot Municipality: �Za T�JC2 , Watershed: SOIL PERCOLATION TEST DATA / Witnessed by: Date of Pre - soaking;, /z -3��2 --- Date of Percolation Test: -7� ZL. /2_ Hole No. • Ran No: Time Start — Stop Elapse Time (min.) Depth to water from sound surface (inches) Start - Stop Rater level drop in inches Percolation Rate min/inch 3 a 1 2-01- 2 ap '1 y - 2 - q, :3D 4 5 I 2 3 4 '5- 1 2 3 4 5' I 2 3 4 5 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obiaiiied 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, pg I of''- P `.ITNIAM COL TY LEPARTAWNT OF.1EtiL 1 H• . - DIVISION OF ENVIRONN[ ENTAL HEALTH SERVICES INITIAL INDIVIDUA /COMN ERCAL SITE LNSPECTION FORM SECTION A. GENERAL INFORMATION_ p Name of Project .i��;ll1 ('1�(V) ibunty, l/ Site Location f Building construction begun ,Extent. Is property within NYC Watershed ? ........:........ es No SECTION B TOPOGRAPHY (Please check all appropriate boxes) 1. Q 'Billy' . Rolling 0 Steep slope Gentle slopeat ' 2. a Evidence of.wetlands Q Low area subject to flooding a° Bodies of wageer. Drainage ditches Rock Outcrops 3. Property lines or corners evident ....... ............................................... yes No 4.. 'Do water courses exist -on or adjoin- the - property? :.......... o .. ....... . ...... �j• Yes � N' • 5. Will these affect the design of the sewage system facilities ?......:..... Q Yes .No 6. Do watershed regulations apply in this development ? ......................... =Yes �No .7. Will extensive grading be necessary ?.......,......................... ................ - Yes! No 8:` R%ill;extensive fill be�necessary for SST. S? ......... ............................... - Yes No' 9. Do filled areas exist within the SSTS area ? ....................... ......... Q Yes . /�No If yes, ghat is. the condition of the fill? SECTION C. SOIL OBSERVATIONS 10. Appea;a ce of soil: [j Sand 'Gravel Loam Clay % =Hardpan f . -1-L ._.- D►bser- ved1rom-=--- -..... ___ Bar ngs_7 - - -... Banlrcut......_:- 12. Soil borings/excavations observed by on 13. Depth'to groundwater on 14. Depth to mottling on 15. Are test holes representative of primary & reserve areas....................................... Qs No 16. _Soil percolation tests made by 1 , \.S -S i on e 7 17. Soil percalation tests witnessed by on SECTION D (on back) Form ST -1 SECTION D. DR. IlINAGE _ 18. Will proposed grading materially alter the natural drainage in this or acljacerrt areas? Yes 19. Will groundwater or surface drainage require special consideration? , .... D. Yeso 20.• Will gullies, ditches; etc:, be filled and watercourses be relocated ? :...................t..... =-Yes [E1N0 SECTION E. REAURKS..- . 21. If a common water supply is proposed, has an jnspection been made of the existing or proposed source and facilities ?...... ..:..... ....:. ....... Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist ?........ ...... � s No 23. 'Additional comments ! - 24. • site observer/inspector and title 25. Date(s).-of observaiion(s)inspecti-on(s) TEST PIT PROMES - .Hole r Lath mole Tr `Lot 4. Hole � Lot r Depth to water Depth to 'water . Depth to water .. - . - - •.._ . - Depth to mottling. Depth to mottling Depth to mottling Depta to rocklimp. - Depth to rockA p. Depth to rock/imp. G.L. 0 .0.5 45 _ 1:0 �?j�avh �.��r~ 1 :0. iiBUn %r �; 1.0 2.0 - "' i 2'.0 )56.K 3.0 3.0 . 4.0 be�� pC, 4.0 5.0 .61-6oh d-" 5.0 6..0 6.0 (o L )mss 'me t G.O. 7.0 .8.0 8.0 8.0 9.0 9:0 9.0 10.0. 10.0 10.0 05/24/2012 16:06 8456352594 MR ROOTER PLUMBING PAGE 02/02 Linda Bardelli 1 Shoreham Drive Brewster, NY 10509 HOME WELL O 45' WELL 10` 1 Shoreham Dr. A B 1 �► � �-- Driveway Shoreham Drive - HOME WELL* O HOME 31' WELL 52' HOME WELL IF HOME Lake Shore Drive 1: Distribution box. 2: 45' leg of leach fields. 5: 15' space in between existing fields. 3: 35' leg of leach fields (assumed, not exposed to verify for leg #3). Perc. Test. A:Left hand comer of home (facing from drive). '::.:: Deep hole tests. B Right hand comer of home (facing from drive). Al: 20' B1: 26' WELL *: Home owners not home to verify location and whether this well is shared for adjacent homes. To be verified and measured. 05114/2012 11:56 MAY - 14-1011 1 o:ZTAM 8456352594 FROKNVIRON+ENTAL HEALTH MR ROOTER PLUMBING r 8482787021 PAGE 01101 T-1e1 P.01/001 P -000 P'UMAM COUNTY DEpART&MNT OF EX4,LTH DWMON OF ENMONMENTAL. MALTjg SEp REQrJ%ST IIDNR6 1 1 Z P, AR h#brmagba must beb& wmpkted,pnor to =y sched Engkow or 1f rm: o r IA Mon! e Person to Contact: .� t ❑ New Construction Q Repak Program ❑ Addition Prognm Mason: gDeeps APeres ❑ ft p Fast Road/Sft eet Town; r�4.? c� ..`.�_ 'fax hup X: Subdivision: Lot #: .` ❑ Project not witblu NYC Watered, WLCMELQR i Oa REVS WI' MSMG YES mil( q Q _ `'pasecl SSTS wititE�a t3 dxa�ittae bra pf i?pest 18uacb, l' b�ai�s, +t�c.]yd's Ctraer ❑ 13 Propmd &ws witwit Soo that of A reesnraai r, nservok stem or cnntrot take. ❑ ❑ Pmpowd S.M w9thin 2W &at of a watuvoum or a DEC weftd. 0 A Prdpoaad 89TS desiRa &w greater du n, LW0 gadtons/dny or WDti S Pemdt required, ❑ ❑ Prosmod SM lbr a Conumn OW Proje& It is the x"poos Wfity of due design professional to provide the above fttffor>Ytation prior to sou to ' This Dgpneppeat will dewm6ne fire NYCDEP projmx onto L?oint or DelegttK based an the raVoase„ 7If you aagsvprsa zM to ate► of the qu n% NYCDEP must wium the svo Waft. This Departmat win enot d ooate a mumal y smWe tbW fbr field testing with Me Dew Prdessiays and NYCDEP. 1tf a predect bas bees deteMW to be Dek$ated b*W on the Wmve r8mp use and thou mWojZwv1 iii &rmnfioa •adi=os NYCDEP Is requ;nd to wftez the sae tesb, ft wM be the sole respons.'baMy of the des%n prncrhlotml to scb ftlWe re- wime=s * of the salt' tasft wfktt NYCDEP. FOR mt3m USE ONLY DAM 'I7ME: Req.f'ar field truly 411612009 1/ r Sheet 1 of 1 _.� Putnam County Department of Health Division of Environmental Health Services Field Activity Report Name: — L.Barrdelli Telephone: _279 -2853 Address: _1 Shoreham rd , Pat. Street Person in Charge or Interviewed: Town Name and Title State Zip Date: 10/4/11 Findings: R- 201 -11, went to site and contractor was replacing pipe from septic tank to D -box about 4 feet long. Contractor is Mr. Rooter Inspector: 4_� C_._ - Telephone: Signa a and Title - - Repbrt,Received.by:_-.o..- - _. -. - .._ _ - = _ I acknowledge receipt of this report: Signature: Field Activity Report. cw Title: Date: