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HomeMy WebLinkAbout2050DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.48 -1 -5 BOX 18 ■ .� � 1' I ,` +T' ` �A ' ' is - . - ' 1 wl 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 �� 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 ..._...= .�DT��S)�O�'N OF'El���fli` MME• l�iF�I;�E�a'�iil- °SERVTC�ES";_> <..��,... .._..x. ,_...: .� FIELD ACTIVITY REPORT '.c1;i4—, "Z v 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': u �,/u2�„! S:P��1�_/Jr Y � �Ll L•� «I i t,. S /-�- �� • T } ' L � G� i Ln �� C��( � ti �i-•� •�i✓s �6 � � /�[ a. G( � K • °fr SAS /� �" G�.O�- r --r.�✓ �z� L . L✓u 5 GJ I %ivt✓� 2.. C.C� i r.✓fyZ. �. {n- e e---t �• ,/�� %• 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 s_ 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 hZ- U m 0 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 A06 F-;k-7 J. SOfVDI LO R -.10 L. I R, L. R-te•. VIS,• 'le— —z)rk Pzaxa !.v 2 2 =2 Pietm=96 -Oticacr ch-5 -r c 1,7-- zz:F-:5 All =4 .-k P S P E P, L I ER. M D. M S.; F. - k' T9rilrr I OP76.- 0�' ;'7�eCib� DEP"RTMEN1 0 - -nevi- Row'. 5rtwS!a-,. New YD r;%- 0 5 0 9 ROBERTJ. BONDI County ROBERT mopMs. Pp- ax Fro j oseph Tq; -Z m S Fax: 3 -7( Pages: Phone- 4 Date. 40 Re: Urgent or Review le se Comment mment Plea P .�e Recycle 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. 7 T e :ISO w C. :r !!U� -VIC j m :;T !U: uxe' ro. i. od 7c; %7. 7 TLan":C wyu. E,TVI-.on,,n enral Heaiui7 3.1 Nun,ul- 5,t!--,!CeS 3-Z :78 Ear-- tnce-venc6)n/'P:,-!s e 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