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BOX 19
02140
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IN
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02140
3/,,86-0 PMAM"COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y 10512
Engineer Mast Provide
_"Permit q�
_
_._.... ; filF_ CONSTRdId' 1N" COMPI: IANCE FOR* SEWAGE •DISPOSAL•STISTEiiS~
Town
Located a WATERFALL LANE Tax Map 4 r ye 16 e l
°o
Block t .
Owner /app cant,Name BILL LUBBERS FormedyROBERT' SIMON Sdbdivisioh,Name FOREST Sabdv. Lot N 13
MaWag Address INDIAN LAKE ROAD _ Zip 10579 Date Penaslt leaned 5/ 21PK
PUTNAM VALLEY,-NEW YORK
Separate Sewerage System built by BILL LUBBERS Address SAME 'AS., ABOVE
Consisting of 10.00 Gallon Septic Tank and 3 75LF .of LEACHING FIELDS,
Water Supply: Public Su' ly From Address
XXXXX NORMAN ANDERSON
or. Private Supply Drilled by B o , o , .. Address
(1) FAM , RESIDENCE
Building Type ? YES
Number of Bedrooms " 3 Has Garbage Grinder Been Installed? NO
FT: 11F' "RATTK 'RTMT FTT.:T.
I certify that the system W 'as listed serving'.the above .premises were'. constructed essentia ly s shown on the "plane of . the completed' work ( copies
of which are attached),'and'in accordance with the etariderds,`rules and regu ions, in acc rd ce with the ad plan, and the permit issued by the
Putnam County Department Of Health.
Date 9/15/86 ce:cined by P.E.-R.A. xxX
Addre:sMUSCOO.T NO, RFD 2. X- 88 OPAC ' NY _ 0 5 J.Lna No. 11056
Any person occupying premises served by the above systems) shall . promptly ankh act n aa.maybe necessary to tat�►e the Correction of any unsanitary
conditions resulting from such usage. Approval of the separate swverage system 1ha11 ecome null,ind void is soon u a pub.:'. tanitary ewer becomes
available and the approval of the private water supply shall'pecome, null and ,void vvti a •pufillc wattar auDply' peCOma available. Such approvals are
subject to modification or cha qe when, in the }udgment of the'Commisaloner of. ' Ithah- revocation, modificatio or change is necessary.
��
Date � By T It N
lu
�l
s.
e
,
If yield was #*sled at different depths during drilling, list below
FEET GALLONS PER MINUTE
,
DATE Ell C PlE '
D O F„QeT. WELL LEFT (S' )tune)
WELL, f O14AP TPON REPORT PU�t�A►M,OWINTY DERATMENT OF MElpllfi
t.
9179 'I;a
i Y
E.nviro'nfn�ioal.' Health* SaardcaF
COUNTY "OFFICE B,UILOING .- CAR11A1 L„ NEW` YOR*
This report
is to be completed by Welly Eller and :ubn rtted 4o County Health Department torther with laboratory spoil of
7. .- analysis of,Water sample Indicating water is of satisfactory bacterial quality before certificate of construction colrrtpliance i>ti btTaued .`
xMUST
REPORT 'SE SUBMITTED— WITHIN 3Q DAYS OF WEAL COMPLETION
OWNER
N ...,. A
,5
LOCATION
.a. Shoot) (Town Plot Noon
OP WELL
.
`
BUSINESS.
® LO ❑FARM D
'
no
DOMESTIC ESTABLISHMENT TEST. WEIY,
USE OF
W ILL
PUBLIC AA A
SUPPLY 1' " NDITIONING 0, OTHER
a �W)
INDUSTRIAL
COMPRESSED CABLE
® ' D
E�Ui ►MINT
ROTARY AIR PERCUSSION L J PERCUSSION ((SpedWl
CASINO
DETAILS
LENGTH 0009
OIAMETE (Inchssl
/
WEIGHT PEA FOOT
HREADEb WEIDEO
I
YES
NA
TES NO
-• -"
YIELD
T50
Nouns WA.'
EI RAII -¢
LED C7 PUMPED COMPRESSED AIR • . 'i
30
YIElO ( P Ya'
tAI
MEASURE FROM LAN; D
'SURFACESTATIC(Speclt feetDURINO.YILDATI[
ST 1f
_Iii Wall E
LEVEE
. /
d /
M feet blow Lund wrfooes �iC7(�
.
15d
AIAaE
NOTN OPEM TO AQUIFEG (roar,
DETAILS
SL¢T SIZE'
DIAMETER (Inches) ;
IF GRAVEL
Diametor of .well f d din® .
C.• a (tl
PACKED:
gravel pods /Ina a).
PeOra {AND EIIRrACE
Sheteh uecl fowthfn of 0w, With OU1~ ".or ieeef
Out :'4
PEEP
Il I TION DESCRIPTION
two pern�enON houfmako.
�l
s.
e
,
If yield was #*sled at different depths during drilling, list below
FEET GALLONS PER MINUTE
,
DATE Ell C PlE '
D O F„QeT. WELL LEFT (S' )tune)
Yorktr Y.,oci��
wn Medical Laboratory, Inc LAB ,;'
321 Kear Street , -�—
YorktownHeights,N.Y.lOS9s Collection Station Used:
�.., T Carmel
s - 1Cie,co P ek li es v k
(911x21 S -3203
F PDtcfor: Ib ad
Date Taken:
�3•ge-71S Date Received:_ /L— /i�"I
/;>/ C /��% W� 2� � .Date Reported:
Collected By: 4L-_--36 ey j
Referred By: et4sS2a,#-DS r°hL*-xPn,*ejV.
L 0006t 701ivA I-Vi 'L �J Sample Source:. /c'i
LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF .WATER
GENERAL BACTERIA
Standard Plate Count per 1.0 ml
(Agar plate @ 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MF.T)
Total Coliform D-er 100 ml
Fecal Coliform per 100 ml
_ Fecal Streptococcus per 100 ml
°°OBABLE NUN.3FR TECHNIAUF •(MPN.)
_ ,Total Coliform ", " M:PN Index -per 100 _ml
_ Fecal Coliform:
OTHER ANALYSES
MPN Index per 100 ml
THESE RESULTS INDICATE THAT THE WATER SAMPLE, WAS (WAS NOT) (NOT APPLICABLE)
G E
OF A SATISFACTORY SANITARY QUALITY ACCORDIN NEW YORK •STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
.Albert H. Padorani, M.T. ASCP), Director
LEGEND
RDS Recommend.Disinfect-
inR Water Source
"< less than
TNTC' Too Numerous T•oo
PUTNAM COUN`T'Y DEPARTMENT OF HEALTH
DIVISION OF ENVI.RONME TAL HEALTH SERVICES
. .p .._ .�.. ... r! ^a. evC ... t�s. P .uc_a¢>r-ar.iV�Y •.D:... „e.a.xs.- i.�s�tcv+'.'t'.a.. ;..'.v. -. ...a ;�:aa'-»s..�.. �Yi.'.. '.:.., .s .�.•r..a .. �.,n :. a.t .. ... .... ... ..,
. t . a �,r >.. ....i ,t.t . -: s�.t., +'.�[r -- }. a..sr. _. e•
BILL LUBBERS
Owner or Purchaser of Building
BILL LUBBERS
Building Constructed by
WATERFALL LANE
Location - Street
PUTNAM VALLEY
Municipality
ONE FAMILY RESIDENCE
Building Type
4 1 16,1
Section Block Lot
FOREST PARK
Subdivision Name
13
Subdivision Lot #
GUARANME OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
:I represent that I am wholly and completely responsible for'the location,
workmanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has been constructed as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years immediately following the date of approval of the
` "Certificate of .Construct-ion. Compliance" for.. the sewage.disposal system,.or...apy._
repairs made by me to ' such - system, except where the failure 'to operate properly- is*- `
caused by the willful or. negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environmental Health Services of the Putnam County
Department of 'Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building uti ing
the system° , . /JV „
Dated this 12 day of S Fp T _ 19 86 Signature
Title OWNER AND CONTRACTOR
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
N/A
Corporation Name (if Corp.)
Indian Lake Rd,Put, Val,,NY
ess 10 579
PUMAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONmEww. PF-AT.Tq SERVICES
INDIVIDUAL KATER SUPPLY SUBSURFACE SEWAGE 1).LbpQSAL SYSTEMS
F= INSPECTION REPORT
INSP. BY:'
(Narriof Owner) (Street Location)
INITIAL SITE INSPECTION YES NO
Wetlands on/or proximate to property...........
Property liiies or corners found. - . .
Can estimate house location ........................... . ....
Will driveway need cut .............................
Must trees be removed - note these.................
Deep holes representative of entire SDS area......
Additional deep holes needed .......................
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacentwells/septics ............................
Access to nronosed well location for drillina .....
D.H. 1 Lot
Depth to G.W.
Depth to rock
Soil Descriptii
0 ft.
3 ft.
6 ft.
9 . ft.-
I
D.H. 2 Lot
Depth to G.W.
Depth,to rock
!Jbil Descriptia
0 ft.
3 ft.
6 ft.
9 ft.
12'. 1t,
D.H. - Deep Hole
G.W.-Groundwater
D.H. 3 Lot
'Depth to G.W.
Depth to rock
0 ft.
3 ft.
6 ft.
9 ft.
12, f t.:--
DATE:
FINAL SITE INSPECTION INSP. BY; -ef -�5�=
YES
NO
COMMENTS
House SSDS located per approved plan .............
7
Length of trench measured
Width of trench average 51/-'
Slope of the line and trench acceptable.........
Rom-allowed for expansion trenches... .........
Over 100 ft. fran watercourse ....................
>
=Slf
Natural soil not stripped or SDS area
unnecessarlygraded...... .......................
10 ft. maintained fran property line and
20 ft. fran house ..............................
Distance well to SSDS (ft.) ....................
Number of bedrooms checks.. ....... 0�1
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ................
15 ft. of peripheral soil horizontally
fran trench.. .........
Boxes properly set...' ...... .. .. P. e-X
... &L?
-7
Could surface runoff fran driveway, road S,
ground surface, etc., channel near SDS area....
Does lot drainage. appear OK in area of SDS.......
FINAL GRADNG OF SITE ACCEPTABLE ...................
L_ -17
�I1. ,�2�' Y',!•m .. .. . � avv�.; ..x �4��Y !. :1 h ,.4.`'C4 1 '( .i. ..`Kl ,1:x �:� 1C!'� f j. 'fw' V �����
` a .`,,..
PUTNAM COUNTY DEPARTMENT OF HEALTH
Rev'. 3186 .Z ti) ; Division of EnvironmeritalHealth s6irvices: Carmel N.Y 10512 EngLseec.to Provide Permit p .
e on CERTIFICATE OF COMPLIANCE
CONSTRUCTION PERMIT FOR SE GE DISPOSAL SYSTEM
Permit q
n Ae
Town or- e
.Located at
Sabdivielon Name T /��! Subd. Lot H Y�I —+ Tax Mapes -Block Lot
L '�����
Renewal-0 Revlslon ❑
Owner /Applicant Name-13.4
Date of Prevlous/Approval
Mang Address f`l V > �.Ki iCE �' <..�� �`� Towne
V Y L. , ��_ Zip
Banding Type / a ^� ` • � { Lot Area 1;,40C
F Fill Section- Only Depth 7/ Volume"
Number of Bedrooms c Design Flow G /t/) 4 PCHD Notification is Repaired When Fill Is completed
Separate Sewerage System to conelst of �Q Gall o n^^SeptilcgTanlr end JaLL /��
To be constructed by �Q i� EA D `� Address iii 0.F V S IN O LL. ZD .: pu T• V A � . , 14.y �
Water SapPIT: Public Supply From Address
or: Private Supply Drilled by 1 Y! 7 Address F— v L' I,.
,.
Other Requirements A
1 represent that 1 am wholly and, completely responsible for the desigi
above described will be constructed as shown onthe approved amendr
County Department of . Health, and that on completion thereof a "l
be'submitted'to the Department, and e.written'guarantee..Will be
place in good operating condition any pert.of said sewage dispol
ante of the approval of the Certificate of Construction Complian
will be located as shorvn on the approved plan and that said well will ti
County Depa tment f Health.
Date I ; @ Signec
Ad I dress A.
APPROVED FOR ONST UCTION: This approval expires one yea
revocable for cau or ma amended or modified when considered
requires a ne rmitt ved for disposal of, domestic sanitar
Date �° By
and location of the proposed_ system(s); 1) that the separate sewage disposal system,
ent theie to and in accordance with the'standards, rules and regulations of e Putnam
aIkificaie. of .Construction Compliance" satisfactory to the Commissioner of Health'will
Lrnished the owner, his cessors, heirs or assigns by the builder, that said builder will
1 system during the Pe o of two. (2) years immediately following the date of the.issu-
e the original syste any repairs th reto; 2) that the drilled well described above
natal in accordant i the stand
S. rules and regu a of the P,uf m
P.E. R A
s License No
f h ` ddte A d unless construct n of a building has been undertaken and Is
ces by missions of H Ith. Any change or alteration of a nsIt tion
sew e, and / p onl is/
Title
f1
1
PUTNANI COUNTY DEPARTMENT OF HtALTH ;
ALTH_: VICES . , ..
::_ DIITISIOTL.,p1� .ElV1lIRQNMIM- TA - --
COUNTY OFFICE EUI C. 10512 .
2
DESIGN DATA SHMT-SEPARATE SEEPAGE -DISPOSAL SYSTEM FILH X100
Owner '�iLC, �a63�3 (G.$ Add e_�s I o�Faaa c.Atc,E 2 :BAST,
?U-E44 k YAL.L.E ,-e�/vy,
Located at (street U)A7�� c:c. Lp ado • docker
t;..:% ; a 10S .171
.. . s Fe ......�.....
� cxosca a near
:.
,.;
•.
Nhanic pality.aa:1��L Watershed
. •'�-
.:.,SOIL PERCOITiO�T TEST DATA BgQUIRED•TO 'SUBMITTED WITIi.-Al?PL %CATIONS
3
..� " ,
Number ..CLOCK.TIME. PERCOLATION
PERCOLATION
t�.ua apse --Depth to WateF a er ve
.
No° ...::......... .....:...:..'. Time From. Ground Surface in Inches-.:
Soil Rate
Start -Stop Min. Start Stop Drop in
Nlin ° /in drop
,. r.. inche-s:M .. '._- -Inches %aches
"
PTH #1 .1...9°45' '•...... "- 10°1.5 30 .15 - 17 °75 2 °75�'•
30/2.75 =11
2....10 a 19..... 10:49 30 15 17.75 .2 0 75
30/2.75=11
3 10-:5.3 ®11 ?, �0. �5 Y7 "_ 7� _ 7�
30Z2.75=11
10:20 30 . -1 19. 333=10
n �A' ,. . T1 22 30..... 16 18.75 z �5 ..
0 30/2 '75 =11 . .
�..
F. '# 4, } }
2
i
�-- {S
sn knS.Y
•
3as S Cat
3
..� " ,
z. x ��
"
5
F. '# 4, } }
°
Notes-
$� obtained a epeated; at same
depth until a ro imately equal soil
rates
axe ,et 0s.eh percolation
test hole. All data to tie submitted
f°or review:
maag
' �pth# ®meats to b® made 8°rom top of hole
o
-d
4
DEPTH
G.L.
6"
12"
10"
24"
30"
3611
42"
48"
54
60"
66"
7211
78"
84"
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE N0. DTK ( HOLE N0. DT'hb 2:. HOLE NO.'
0 P J0 I L SOP �So «.
SAtqD a CLAY
r .
INDICATE LEVEL AT_ MCH GROUND WATER IS' ENCOUNTERED Nvr4 E
' INDICATE- 'LEVEL" TO °WHICH WATER- //LEVEL RISES AFTER -BEING •ENCOUN- - NON..
TESTS MADE BY �lo��, C�jvG��a.� DateT�
DESIGN
Soil Rate Used Min/1 "Drop: S.D. Usable Area Provided .60 0 SE
No. of Bedrooms Septic'%hk Capacity' ODD _.,Gals. Type 5 ti[c,
Absorption Area r� o— vid By L. F. x24" trench.
Name Joel Greenberg- Architect I Signature
MuScoot North "
Address; R Ma•Fho.D. N2, Box 46&
pac, NY 10541 SEA 3
THIS SPACE FOR USE BY HEALTH ' DEPARTI4ENT ONLY: ��'� a� "° -ld�
NE
Soil Rate Approved Sq. Ft /Gal. Checked by Date
vy ,
PUTNAM COUNTY"*DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_q
Date
Re; Property of
_
Located at WATER-FISLL LAME---
A
(T) Section lock-1 Lot
Subdivision of- FOR-t-ST
Subdv. Lot # _Filed Map # -Date
Gentlemen:
This letter is to authorize itc-c- �R_ro✓l3r_-"
a duly licensed professional engineer or registered architect,-A-
(Indicate)
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam C6unty
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or.systems in conformity with the provisions of Article 145 or
147, Education Law, the Public HeAlth Law, and the Putnam County Sani-
tary Code.
Cou
P.E.k,,,JRA.,#_j Q,15
L _�q
Joel Greenberg-Architect 1
Muscoot North
S R.F.D. #2, Box 488
7 Mahopac, NY 10541
Telephone
01. Very truly yours,
S i g n e d
ner of Property
INMAN LAb"-- F—D. g-�W-E_
Address
L
Town
Telephone
W °.
COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVI
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEDGE DISPOSAL SYSTEMS �b
..REVIEW` SHEET.- QQNSR UCTION PERMIT
� J
.DATE
vV ,_ BY:
(Street
YES
NO
Lion)
DOCUMENTS
_
Permit Application
Corporate Resolution 'Z '�'2
,
Plans - Three sets
Engineers Authorization
Design 3
Data Sheet. ( DDS)
27
Deep Hole Log'
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans sets
a
If PWS - Letter
Variance Recluest
REQUIRED DETAILS ON PLANS
Sewage System Plan
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile `& Dimensions.= Volume
D or J Box;TFrench /Zallept; am@ pia deta
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
Expansion Area; shown;gravtr_flow,suff. size -
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
House Setback (Tight lot)
House Sewer 1 /4" /ft. 4 "0; Type pipe
No Bends; s 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains- irtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' from Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
(Town/DEC Permit R & D)
DDS Plans & Permit Same
� C
5l
`-
11-16. �O
_ Q)
F' 127 ssos
"�
rlQ) ' " �o'pe�uws ' ���u,c`"�� |� |
NO
71�_BAFFLO
c 4 5
A,,:04% '
OV
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-tj j"mnopIP
_
`-
11-16. �O
_ Q)
F' 127 ssos
"�
rlQ) ' " �o'pe�uws ' ���u,c`"�� |� |
NO
71�_BAFFLO
c 4 5
A,,:04% '
4
�oo.
��.»v"v/.,^~
�L^^n.00'
OV
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DRAINAGE W.11 'SEIPT14TA#%L�
A-J-29
EASEMENT
JA., 07.0..O"�/
DICKTOWN
ROAD.
4
�oo.
��.»v"v/.,^~
�L^^n.00'
�^
THIS IS ,"C=xzIrx THAT THE uowAmo nzupouuL mxurom WAS cum-
uTx INDICATED ON THIS Pl.,AN.AU TUAT THE SYSTE14 WAS
INSP ECTED BY ME BE009E IT WAS COVERED OVER. THE SYSTEM WAS
CONSTRUCTED 10 ACCORDANCE WITH ALL STANDARD RULES-AND REGU-
LATIONS OF THE PUTNAM - COUNTY DEPARTMENT OF HEALTH AND THE
NEW. YORK ~^~^~ ~~~^^^""°^ OF ""°Lzn'
�
-- ''
OV
'
�
A-J-29
f4flo'
�^
THIS IS ,"C=xzIrx THAT THE uowAmo nzupouuL mxurom WAS cum-
uTx INDICATED ON THIS Pl.,AN.AU TUAT THE SYSTE14 WAS
INSP ECTED BY ME BE009E IT WAS COVERED OVER. THE SYSTEM WAS
CONSTRUCTED 10 ACCORDANCE WITH ALL STANDARD RULES-AND REGU-
LATIONS OF THE PUTNAM - COUNTY DEPARTMENT OF HEALTH AND THE
NEW. YORK ~^~^~ ~~~^^^""°^ OF ""°Lzn'
�
-- ''
_'lkU7NA- VALI.Fle,W.V. Pr-2~� APPIZW=n �10,1131'86
JOEL LAWRENCE GREENBERG
ARCHITECT— TOWN PLANNER
`
mvomwr NORTH n
� " 03. 3*1 *48 NEW V a ex 142,41
sags
OV
'
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_'lkU7NA- VALI.Fle,W.V. Pr-2~� APPIZW=n �10,1131'86
JOEL LAWRENCE GREENBERG
ARCHITECT— TOWN PLANNER
`
mvomwr NORTH n
� " 03. 3*1 *48 NEW V a ex 142,41
sags
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
SITE LOCATION 54o i21G1 4RfXV►ttc: zL_Q TOWN Off m TM # 30, z . ZO_
OWNER'S NAME �ALlMK ?fue LA � MFtRfNA 82 PHO.NE4 LZS• 1,963
MAILING ADDRESS S4o XA6 AIZ— PSV1U:E RDP KA MEt� �rf- los i2
APPLICANT PANGuA JqV OWN S
Name $ Relationship (i.e., owner, tenant, contractor),
DATE 0(2. 18.40 FACILITY TYPE 'sgpr -rANy_ PCHD COMPLAINT # h t
PROPOSED INSTALLER -t-, p N(. U,W01110mvf PHONE # q pZlq
ADDRESS i�7 (WAS�,uGnp,U ��. -�- = REGISTRATION /LICQNSE #
i.c7Sb(,
Proposal (include a separate sketch locating the house, property fines, 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.
'M ffka,06AyE TlIL;' Sa?Pn TANK_Sy 13E tQ' tR A_OfgaD H c ADDinGnJ.
1, as owner,agree to a conditi s state o is form
SIGNATURE , TITLE DATE (pj• O� •O�
(owner)
1, the septic I e , a e o ply with the conditions of jthnis.rmit for the septic system repair
.� _- SIGNAT-0EiE_ . _ ..:-.. .... � TITLE ~DATE ^09 .0`91•0$--
(installer) 11 V11
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 ❑
z r�
Z�
Inspector's Signature & Tit e Dfite Expi ation Oate
Repair proposal is in compliance with applicable codes Yes 0/ No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
LETTER OF TR.ANSMIT'TAL
CRONIIN ENGINEERING P.E.9 P.C.
The Lindy Building; Suite 200
2 John Walsh Boulevard
Peekskill, NY 10566 ��
914- 736 -3664 Fax 914- 736 -3693
Gene Reed, Public Health Engineer
Putnam County Department of Health
4 Geneva Road
Brewster, NY 110509
Sent via overnight mail
RE: Panella -Ho Site Plan
Richardsville (toad, 'town of Putnam Valley
THESE ARE TRANSMITTED as checked below:
September 09, 2009
0 FOR APPROVAL ff FOR YOUR USE SAS REQUESTED ❑ FOR REVIEW AND COMMENT ❑ PLEASE REPLY
REMARKS
Find enclosed four copies of the Site Plan, the application form and a bank checkfor
$150 for the septic repair permit for the above referenced project. The project involves a
proposed addition to an existing house and a detached garage. The reason for the
_ repair permit--is- #hat --the e_ xisting -1,000,.gallon septic tank needs - to: be relocated: to-a.....
minimum of 10 feet from the proposed house addition.+ M
There is no failure of any aspect of the system, just a dimensional requirement that
needs to be met for the house addition.
Kindly review at your earliest convenience. Should you have any questions or require
additional information, please contact me at the above number. Thank you for your time
and consideration in this matter
Copy to: James Panella and Marina Ho via email
Signed: Keltl
Cronin Engineering, P.E., P.C.