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30.18 -1 -7
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02169
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT R- 22
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Internal Use
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
PERMIT#
within 200 ft. of a watercourse or DEC - mapped wetland ❑
C,�k-t , /1,*6- /IP TOWN fU�N�u»
Not in Watershed
Delegated
Joint Review
TM #,
a o yam'_ 11 Pd_ 7^A',a
DATE I I 04 FACILITY TYPE /Aft AC) PCHD COMPLAINT #
PROPOSED INSTALLER Pc ZZZJI0 A /Us ,:vC_ PHONE # %¢'%3y 3*s-
ADDRESS '? 'Cbj W,9ob 413, (dt- / ,q,,V/)r/44 v,.REGISTRATION /LICENSE #
/y-,
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) lk go u E
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature nd extent of the repair.
a-
trd S40 L C ou44A- , �% 3 ;Z.�;t„ s f 5 e. (A :,yy' .7' i3e k �: s
I, as owner,agre o th_ conditions stated on this form
SIGNATURE 46MI04IT-ITLE
DATE P /'r_0
(owner)
-- • — •'I; the-septic' irtstaller; agre��tb-complywith the- conditions -of -this- perm it-for the- septic-system, repair,- _....... _.._.._....
SIGNATURE 0 0 /,j,, TITLE DATE O
(Installer)
Proposal approved with the following conditions: s
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 ❑
vc
W.
Inspector's Signature & Tpe [date I Expiration Date
Re air proposal is in compliance with applicable codes Yes ❑ No JZ
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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A.i LICX WC- 4149 -1191 PIZZELLA BROTHERS, INC.
•,tiP `.' LIC.#PC -192 "
• SCALE: N APPROV D BY: DRAWN BY: .�
DATE: 3 2 REVISED:
L4uoj 0 rL 305 LAh c
3 DRAWING NUMBER:
Pao ��e
i
shect of
PUTNAM COUNTY DEPARTMENT OF HEALTH
NVI•ONME.NTA-L-HEATLIT SERVICES ;
FIELD ACTIVITY REPORT
N A N4F: Ifd:
------- ----
AT)T)RF.,.O,: 3ej
Street Town, State -'Zip
PERSON IN CHARGE
ng TNTFgymmma. Dgtt-., ZS z /14
Name and Title:
TYPE OF FACILITY:
FINDINGS:
IV
A
Signature and. Title
REPORT R-F.('-F.TVF-T) RV.,
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
SITE LOCATION.
OWNER'S NAM
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
1 SA _ _ OR SEWAGE 1 � 1 � \ REPAIR
MAILING ADDRESS SPiMe-
OFFICIAL USE ONLY
�i-aQ V-&3
TM# /?-/-7
PHONE At % 11:2-0 C`
PERSON INTERVIEWED PCHD Complaint #
e & e a ons p i.e., owner, tenant, etc.
DATE �� k � 0 - TYPE FACILITY
PROPOSED INSTALLER p�ti'�� � PHONE �3 �-� 0
ADDRESS
REGISTRATION# .
r a (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
.may require submittal of proposal from licensed professional engineer or registered architect.
cL Goo OA, on 6�eeA
._ .._ .I, as -owae ,- or'r1p ed agents er agrce to -the conditions - stated on ibis -form: --. ._ -.- .y_:.::::..__::.-�. .-
SIGNA TITLE el DATE /
Pro on sal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title /DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 9%M
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TO: Nancy Collier
FROM: Karen Yates
DATE: February 6, 2009
RE: O'Connor Septic Repair Refund
Please refund John O'Connor at 305 Lake Shore Rd:, Putnam Valley, NY 10579 $100.00: Susan
applied for a Septic Repair Permit on,February .6,.2009 and paid with a tellers check # 59579 for
.-- .. - -•- ". $250:00 aiid the--application fee for'a-repair "is ,$156.00. - She is eiitifled to a refund of the -
difference.
Thank you.
J
- Standard Infiltrator® Chamber
The. StZrldafd,Infiltrator chamber4s44dw•�0rofile unitwith a'6' =indh ' sideewall.
Also available in 'SC /Shallow Cover model.
m: x'
Ibs (1.1kgt��as�J., P.1 * ��-
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INFILTRATO
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Standard -SideWinder' Chamber
The Standard SideWinder chamber combines the advantages of the Standard
Infiltrator chamber with the revolutionary SideWinder sidewall. Also available in
SC /Shallow Cover model.
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'$Ize (W,X� H) 4 ...34" x.75" x 12" `(85 cm ,x .1. VcM x 31 cm)
�filll(Qlgfat .29.Ibs (13.2 ..kg)
s. r.i:.r: v�:•:, r• .. .. • .. Lr ; f 4x13' ari -
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X�e��ediSldewall Height. .6" (15 cm) w,
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(Equalizer'* 24 Chamber
The Equalizer 24 chamber system is the optimal Jhoice for narrow
trches and utilizes SideWinder technology to aximize infiltrative area
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Contour" Wedae
The Contour Wedge provides extra flexibility to accommodate natural terrain features
and avoid obstacles. The 150 angled unit interlocks securely to chambers or oi0or
Contour Wedges. Available in two models for left or right turns, it can be used Ah
the Standard, High. Capacity and SideWinder chambers.
Standard Cpntour Wedge
Sf7tfklNi.L� {.rH):5;:34x.9.5' x,>)2' <(85 cm.x 24 cm 31 cm)
t.Welght r~; �'.;: .3.5 Ibs; (i.6
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High Capacity Contour Wedge
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Welght `.. ; ....4.Ibs (1:,8.k9).
Storage CapAcity ..13 gal (491) • .
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Contour'" Chamber
The Infiltrator Contour. chamber accommo-
dates natural terrain features and avoids
obstructions. It has a unique angled end that
can be adjusted from 30 to 90 for a left- or
right - curving pattern with a 40 ft (12.2 m) to
120 it (36.5 m) radius.
'Length measured along center line.
FEB -14 -0302 00:34 FROM 292 MAIN STREET TO 12123080642 P.02
PUTNM COUNTY DEPARTMENT OF -HEALTk
DIVISION OF ENVIRONMENTAL HEALTH SERVICES-
Date-
Re: Property of {� L 1 L� � � fl � L l_
I��saanem .• I
Located at GAYC SN-key -e DRNyE
(T) PkTV'kM Vi4!� ( Section $lock Lot
Subdivision of � \� fL � e'lA P b� �@ 11KL�u� l�S�FJ� ( A 4EIE:-
� n+
Subdv. Lot 0 1 Filed May # bete
Gentlemen:
This letter is to author i.7541
a duly licensed professional engineer J or•registered architectw�
(Indicate— ��ll
to apply for a Ccnstructian Permit for a to
r
sorve the above rioted property in accordance with the' standards, males
or regulations a$ promulagated by the - Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this mattes and to supPr-v'isie the construction of 'said
system or systems in conformity with the provisions of Article 145 or
___......._._. _.i47t Ei3uca ioi a,dw,. H Pubaac- Health -L-avi —and the- Putham •County. zni-
tary Code.
Very truly yours,
J Sigaged „z C
Countersigned. �z -min Owner of Property
313 6
15) CE4-2T"L PArCzK vi 'EST
Xadrese.
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255 —w32
Telephone
Town
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-
Apartment #6W
New York, NY 10023 -1514
Tel: (212) 769 -9732
September 17, 1997
Putnam County Health Department
Route 312 and Geneva Road
Brewster, NY 10509
Gentlepersons:
Enclosed is a Well Completion Report relating to the
above property, prepared by Boyd Artesian Well Co., Inc.
Please file this report as appropriate.
Thank you for your assistance.
Sincerely,
Alice Rudell
AER /lp
Enclosure
72418 -1
9999/08
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APP1,1CATION- ..TO CONSTRUCT A WATER WELL � >
PCHD PERMIT 0
WELL LOCATION
WELL
Street Address Town/Village/City Tax Grid
LA Kr S ftv.F_ ts,(t \v r Ikw m'\ v t.LF 1
Number
WELL OWNER
Name Mailing Address rivate
AL.LLF, P,LV)SLL %51 CEw4�,k Vj,_ck A �. 6W N1_ 1JA, 11 Public
USE OF WELL
1 - primary
2 - secondary
'
&RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ® ABANDONED
0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
® INDUSTRIAL O INSTITUTIONAL O STAND -BY a
AMOUNT OF USE
YIELD SOUGHT VveA S gpm/ # PEOPLE SERVED D /EST . OF DAILY USAGE 2 Sal
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
(L0 ryFt _1_z °tom "pPj_CMFNT viftNS L
-5LgP Ly
MA)(A 1_45 56. 0 I.0-0 y'V_C_ `M "64.14 '5uV-0- iz
CL KATE .
WELL TYPE
DRILLED
ODRIVEN
®DUG ®GRAVEL
®OTHER
IS TELL SITE SUBJECT TO FLOODING? YES "-NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: RoA- Rtt3(r 131udk
Lot No. L,07 J/'0 ! PM 3 t) G
A
'STATER WELL CONTRACTOR:
Name 9_.PAC�N K5PO-S ��"
Address:
��'�' IOSZ�¢
IS PUBLIC WATER SUPPLY
AVAILABLE TO SITE:
YES ✓
NO
NAME OF PUBLIC WATER SUPPLY: N�l� TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER-MAIN: �
LOCATION SKETCH & URCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
4z\ Y
(date) (signature)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Suipart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
provided by the Putnam County Health Department.
Durin; all well drilling operations, the applicant shall take appropriate action to assure that
any aid all water or waste products from such well dril ing operations be contained on this
property and in such a manner as not to degrade or of ise c aminate surface or groundwater.
Date of Issue: � 19 qj 1
Date of Expiration 19—IF Permit Issuing Official
Perm :: is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION. TO CONSTRUCT ;.I , :j+1ATE,Ft_yT LL.;.__.,,
PCHD PERMIT # w I
WELL LOCATION
Street Address own/Villa �gg C y Tax Grid Number
305 koye Ujr Vc�, _ 3o if' 18'-1 -f7
WELL OWNER
Name
LW- 21jotao
Mailing Address
ui & K+,U -Q
f ,Private
k-/. LO, 04 LOO 13 0 Public
USE OF WELL
1 - primary
2- secondary
O RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
0 INSTITUTIONAL
❑ AIR /COND /HEAT PUMP 0 ABANDONED
O TEST /OBSERVATION 0 OTHER (specify
O STAND -BY 0
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE
SERVED /EST. OF DAILY USAGE 5 ^JO gal
REASON FOR
DRILLING
REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION 12- ADDITI NNAL SUPPLY
❑ NEW SUPPLY NEW DWELLING ) L] DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
[3DRIVEN
0DUG
GRAVEL 0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES K, NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name WL/W /fi/j T-0S(4 t4 I AJ W (,,} , Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _NO a_ SL4�
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
�r ®.ON SEPARATE SHEET -4
(date) (signatur
PERMIT TO CONSTRUCT A WATER WELL
1of
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on.'this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19
Date of Expiration
19
Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
N�lj g `(" *b D ro
Ho f"s Q
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F)l el as , s
I- TANS
(D PJvo\,Nali,
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE' SEWAGE TREATMENT SYSTEM
-
Owner: l`/ �� �� Address: 305 4d4kc 5//0 e 711)Iz1
Located at (street): TM # SectioO: 11B lock' ( ` Lot 7_
Municipality:', P,07u .�V,4Lz-,6 y Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre - soaking: Date of Percolation Test:
Hole No.
Run No.
Time
Start —
Stop
Elapse
Time ..
(min.)
Depth to
water from
g round
surface
(inches)
Start - Stop
: Water
lever drop
in inches
Percolation
Rate
min /inch
Z
3
-
-
.5
'
1
2
3
4
1
2
3
4
1
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., <.1 min for 1 -30 min /inch, < 2 min for 31 -60 miniinch).
All data to be submitted for review.
2. Depth measurements'to be made from top of hole.
Form DD -97, pa I of 2
TEST PIT DATA
DESCRIPTION. OF SOILS ENCOUNTERED IN TEST BOLES
Design Professional Name:
Address:
Y
Signature:
Desibn Professional =Seal
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DEPTH HOLE #-__L_ HOLE # HOLE #. HOLE # HOLE #
G. L.
1.0'
7eaQ rtn�
2.5'
aM
3.0'
-
4.0'
ecP
4.5'
-¢
5.0'
Sc�
6.0'
6:5'.
7.0'
8:0'
No &iUb(4,r
8.5'
lzoak
• . 9:0'
9.5
10.0'
Indicate level at which groundwater is encountered A)o j9
Indicate level at which mottling is observed AjoM,;_:
Indicate level to which water level rises after being encountered
Deep hole observations made by:. �� ► F,>4 Date :5
Design Professional Name:
Address:
Y
Signature:
Desibn Professional =Seal
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^EOCRAPH /C INDEX 527147 643773
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SURVEY OF PROPERTY
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PREPARED FAR
t JOHN D'. O gCO NOR
Area
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A c� ,9S
AGRUPPU.S'O
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Pw� -9TUA lE IN WE
TOWN OF PUTNA�bP /ALLEY
Ws mop was prepared for the excluslns
use of and Is cert fled only t-
Notes
1. copymCHT 70OJ" by BADEY & WA ISM Surveying Lion of cpp P.G p PUTNAM COUNTY
All Rights Resermd. Unauthorized duplication is o nation of app /icob /e NEW YORK
xv/N D. OCONNOR
LARETTA ARUPPUSO
-
/ows '
2. Unauthorized alteration or addltl- too document''Wored by a SCALE 1 in. = 50 ft. AUGUST 19, 2003
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