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02050
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
0
YES Nff Internal Use Only
PERMIT # [3- vv- J
❑ Repair Permit issued in last 5 years
❑
❑ Not in Watershed
ALDelegated
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ . Repair within 200 ft. of a watercourse or DEC - mapped wetland
❑ Joint Review
SITE LOCATION 1$1 FAIK -%F- D DfJIJE TOWN PAITTE�4oH
TM #7 ' G-48 - I - 5
OWNER'S NAME j�I T1�Ot 1 i044A ,k P- 00PCaOE1,
_
PHONE # 91`) _ 7L"col?0
MAILING ADDRESS 0959°
APPLICANT �Q- 1i4►-a1��17 -- , LQt- ifr- Ac�b¢-
Name & Relationship (i.e., owner, tenant, contractor)
DATE y ' "?'o " do FACILITY TYPE
PCHD COMPLAINT #
PROPOSED INSTALLER I fl-+0P1A- 65Pr111 %i �fEMyj
PHONE # OAS) 1-1i- 4 %0J
ADDRESS K`I REGISTRATION /LICENSE # to a
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.
564 A TTAGttEv PI-AH
0
I, as owner,agree to the conditions stated on this form
SIGNATURE �° Q� TITLE a!4.4, DATE 101 6l
(owner)
- - I•,--the septic!nstaller; agree to comply with e,condit'ons-of this permit forthe-septic system repair-- -
� � ICE
SIGNATURE TITLE DATE
(installer) 4 or
Proposal a r wN/ o con i ions.
1. Procurement of any Town Kermit, if applicable.
ubmission 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
/` ompleted SSTS repair will function.
�/ o completed work is to be backfilled until authorization to do so has been obtained from the Department.
r� _ INTERNAL USE ONLY
Pro al Appro Proposal Denied ❑
Ir
In ector's Signature & Title Date Expiration Date
eoair proposal is in compliance with applicable codes Yes 0 A<
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
To:
C
Attention:
Gentlemen: We enclose ('copies of
%#n Prints O Reproducibles
❑ Specifications
Harry W. Nichols Jr., P.E.
P.O. Box 252, .
Brewster, NY 10509
Tel. (845) 279 -4727
Fax (845) 279 -4728
Date: a
O Memorandum _
Job No.:
0 Ct —06
Project
O Reports ❑ Tracings
O Copy of letter ❑
Description: Revision/Date No.
Aovi
Sl- /3y
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to
Sent Via:
Our Messenger O Blueprinter O First Class Mail O Special Delivery
O Your Messenger O Hand Delivery O
Copy to
Very rely yours,
any W. i ols Jr., P.E.
i
O Reports ❑ Tracings
O Copy of letter ❑
Description: Revision/Date No.
Aovi
Sl- /3y
��
to
Sent Via:
Our Messenger O Blueprinter O First Class Mail O Special Delivery
O Your Messenger O Hand Delivery O
Copy to
Very rely yours,
any W. i ols Jr., P.E.
J
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
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FIELD ACTIVITY REPORT
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ADDRESS: /� � �, /�i'�tic' ,��►1,e ��i��
Street Town State Zip
PERSON IN CHARGE /LCio`t e,rl.;"`
f D��
Name and Title
TYPE OF FACILITY.: �.� i,?�..i(iL ! .
FINDINGS: 07(- /(Q�IJ� ✓r/ �„� f 4�l,- rG!'t.i.,� Vii':
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I acknowledge
02/96
.41 V LJ-1 1 ltll.
n Rv:
t of this report: SIGNATURE:
Title;
SEP -16 -2009 11:26 AM HARRY W NICHOLS
SHERLITA AMLER,1► % MS, FAAP'
- Commissioner of ftealth - - -
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Hwlth
91.4 279 4567 P.01
.0D(
ROBERT J. B "ONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
REQUEST.-FOR FIELD VESTING
All information below must be fully completed prior to any scheduling, DATE:
ENGINEERING FIRM: rte , Cw r PHONE #: � j 7 Z�
PERSON TO .CONTACT: 40sc W
❑ NEW CONSTRUCTION "REPAIR PROGRAM ❑ ADDITION PROGRAM
t yeyo J ti r
REASON: DEEPS: PERCS: PUMP TEST: ❑ --��--
ROAD /STREE'T:� lz l
AJd
TOWN:. - -- Rarerg t-t _ !` , TAX MAP #: '3Cow�1
SUBDIVISION: LOT #: ----
OWNER: _/�� �C,� -i, � ,r � t i �f^ ► a � 73 f=_ c,
NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING'OF SOIL TESTING
.__.'YES •NO
a ❑ Proposed SSTS within the drainage basin of West Branch or Boyds Corner &
Croton palls Reservoirs.
1-3 Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
❑ 0 -Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required.
p ❑ Proposed SSTS for a Commercial Project.
It is the responsibility of the design professional to provide the above information prior to soil testing.
The Department will determine the NYCDEP• project status (Joint or Delegated) based on the response.
If you answered rtes to any of the questions, NYCDEP must witness the soil tests. This Department will
coordinate a mutually suitable time for field testing with the Design Professional and NYDDEP.
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 will be the sole responsibility of
-the design professional to schedule re- witnessing of the soil testing with NYCDEP.
FOR COUNTY USE ONLY
DATE: ZI - TIME• lt7 ° L 9
COMMENT T
neq. rortrc®nrstrrt+a,tc�Y Environmental Heftllh (845) 278 -6130 Fax (845) 278 -7421
Water Supply Section (845) 225.5186 Fax (845) 225.5418
Nursing,Servtces (845) 278 -6358 Fax (843) 27W26 WIC (845) 278 -6678
Nursing Home Care Pax (845) 278.6085
nr_.a_. r_•-- .-- `.-- Iti_-- -L __106 A Ok AMD fAIJ A_.. 15A C% f/16 ee /e
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PUTT AINI COUNTY DERA.RTNIEIi {T OF HE?LLTH
DIVISION OF ENVIROIViVIENT_AL,I-IEAI.TH SERVICES
DESIGN DATA SHEET-- SLiBSURFA CE SE Vi' AGETREATMENT SYSTEM
Owner: f ✓>rl �e e _ Al Address:
Located at (street;: �S 1 ,�'Ie. Vhzl nliz TM # Section: — Block Lot
Municipality:. 1 G..7.d *- -' Watershed:
SOIL PERCOLATION. TEST DATA
Witnessed by: NSF'. PG *14-
Date of Pre - soaking: Date of Percolation Test:
Depth to
water from
i
Time. Elapse ground
titer �ercotation
No. Run No. Start —
I-Iole ?V S a Time i !suet drop I Rate
Stop (min:) ( surface ( in inches. I rain. /inch.
(inches) i i
Start - StopI
j 1 o: 14 5- �" 3 1
y i
i 2 �`8-.Id a
4
f i 2
f , 3
I
I 3
I I 4
i
I ? i. 1
j 3
4 1
tiotes:
1. Tests to be repeated at same depth until approximatel v equal percolation rates are
obtained a: each percolation test hole. (Le.. < 1 mir, for 1 -30 min, inch, < _ min. for -oG min inch).
All data to be submitted for review.
_. Depth measurements tc , made from ton of hole.
_ -Vc7 .1
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d
m �'T',` tn
MEMORY TRANSMISSION REPORT
TEL NUMBER.: 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 799
DATE OCT-19 11:15AM
TO 812127491375
DOCUMENT PAGES 002
START TIME OCT-19 11:15AM
END TIME OCT-19 11:17AM
SENT PAGES 002
STATUS OK
FILE NUMBER 799 SUCCESSFUL TX NOTICE
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Fax: 3 -7( Pages:
Phone- 4 Date. 40
Re:
Urgent or Review le se Comment mment Plea
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Please Rep,iy, '-7
In the event -or' umns-mission•receprion difficul-ries. piease conuact rile
Envirorimenu
(11 HIS" office ar (8455 8-5 IL-350. Thank vou.
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
EWAGE TREATM
Internal Use Only . PERMIT #
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
Repair within 200 ft. of a watercourse or DEC - mapped wetland
• vl �'
1�
w
❑ Joint Review
SITE LOCATION 181 I`AIP -F1F_W DNvF_ TOWN PATTP -60H TM # '�G,4$ - 1 -15
OWNER'S NAME AHT 0Q1r . i 600+404%"A %-DDA t IaUG'- PHONE # 914) - 7L_ 6IZO
MAILING ADDRESS
APPLICANT 010 -1 ik N &l; 6"o-- , L C 14ri -A `-<09—
Name & Relationship (i.e., owner, tenant, contractor)
DATE �°� "3o - 0,� FACILITY TYPE R6l DE3 -ICE PCHD COMPLAINT #
PROPOSED INSTALLER eft- �DPKU, 6EPriL, �7i M�j PHONE # `SAS) ?-1 4%0
ADDRESS - 1y'i 1k11.L 4, 8 -I 1`q IW�C� REGISTRATION /LICENSE # PG - 1'-3
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. w
I, as owner,agree to the conditions stated on this form
SIGNATURE ' TITLE2 ,U�, _ DATE /0007
{owner).-.:..- -
- I; this septic'instaltef, agree to comply w4ia iijbbn"s-of this - permit fdr the septic system repair SIGNATURE�TIfLE DATE (installer) Pro osal a r t o c
1. Procurement of any Town Kermit, if applicable.
ubmission 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
ompleted SSTS repair will function.
�o completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
71nector's l Appro � Proposal Denied ❑ lo�_e4dc,_
/,c X
rC
Signature & Title Date Expiration Date
eoair Dr000sal is in comDliance with applicable codes Yes 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
To: r i�- 14 O
Attention: �0� �P�Q- F�►�I�Ci� , d��l��
Harry W. Nichols Jr., P.E.
P.O.Box �...-
Brewster, NY 10509
Tel. (845) 279 -4727
Fax (845) 279 -4728
Date: 0`.) -- 7O - a°,
Job No.:
Project `�—J'5 app`4 " N=-Ci* -
(T) p,�r', �o►-�
Gentlemen: We enclose ( ) copies of
( W2/ Prints O Reproducibles O Reports
O Specifications O Memorandum _ O Copy of letter
Description:
'ufkPO6Aj- F-O - gEwAGI� 1 L WME�rr'' -19i�y'jTH 4P#�,14
M'5)(A1-H DATA yj 1
) l l P-FPM - Pr.AH
Ao1'LIGf'��IA}-+
7 Se t Via:
Our Messenger D Blue Tinter
g p
O Your Messenger O Hand Delivery
Copy. to OPAA ' $EC+V-
O Tracings
O
Revision/Date No.
og - '-�o 09
0°)
6:49.- 10._ Oy
❑ First Class Mail D Special Delivery
O
Very truly yours,
Harry W. N �c ols Jr., P.E.
PUTNAM COUNTY DEPARTMENT. OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner /,VATftlrdi r 60-""A Addressqo 6IA0 1511 K It BWNE�.► 11)501
Located at (Street) I F04LAeW OR--I r444%k 4 Tax Map Block I -Lot
(indicate nearest cross street)
Municipality PATTIF 01-4 Watershed
SOIL PERCOLATION TEST DATA
I.A
Date of Pre-soaking Oa Date of Percolation Test 09
xom�
I F
. . .. .....
. .. . .. .
. ..... . ..... . .....
xb.
. .........
. ...... .... ..... ..
102 10'" alil- 145,11- G j
2 1() 01
3 VL
.o
4
5
2
3
4
5
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. s I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be
submitted for review. - I -
2. Depth measurements to be made from top of hole.
Form DD-97
Indicate level at which groundwater is encountered V40H5
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered N h
Deep hole observations made by: J05EPN FAM011 i PCIAO N{W W • H►(h10 6 - Date 09124 101
Design Professional Name: HAW W. HiWOL6 4. PC —
Address: 60k 9-51— :. - -...
�P e� ;
.� .. o
Signature:
9,41, IAW
No 66124
Design Professional's SQ1MIT Nd�'`" P`'
UF
S
TEST PIT DATA 2
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH_"
�.�-._ - HbEFN'O: "'
G.L.
d.5'
1.0'
2.0'
2.5'
3.0'
3.5'
MOWN\
4.0'
,
4.5'
1 - StJmE AIL .
5.0'
5.5'
6.0'
X6].5'
/ .0'
8.0'
8.5'
9.01 _
9.5'.
10.0'
Indicate level at which groundwater is encountered V40H5
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered N h
Deep hole observations made by: J05EPN FAM011 i PCIAO N{W W • H►(h10 6 - Date 09124 101
Design Professional Name: HAW W. HiWOL6 4. PC —
Address: 60k 9-51— :. - -...
�P e� ;
.� .. o
Signature:
9,41, IAW
No 66124
Design Professional's SQ1MIT Nd�'`" P`'
UF
7