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41.15 -1 -5
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02381
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PUTNAM COUNTY HEALTH DEPARTMENT�yo .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES r--,
SYSTEL4 RIERAIR
N
YES NO Internal Use Only PERMIT -
❑ Repair Permit issued in last 5 years Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
39' j0gwk51 TOWN -PU TY #^& r TM #q %r /S — / -.
FxAt * 2.6IK o ,�_21_I PHONE -# 91 V T Pd VS'63
& Relationship (i.e., owner, tenant,- contractor)
DATE 1' ® FACILITY TYPE fp E S PCHD COMPLAINT #
PROPOSED INSTALLE WA (54 136 F_ R- T PHONE # �w �� �a, C
,A '?& csc q
ADDRESS 'PJ iFt- 4 pA VA, L.0 -4 /y ;� _ � REGISTRATION /LICENSE # Jp 5d
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.
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE O u1� yy DATE 3
(owner) _...
I; the septic -inst filer, agree to comply with the conditions of this permit for the septic system repair � -
SIGNATURE TITLE A6CK T DATE a
(installer)
Proposal approved with the following conditions: t
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 backfill d until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved tn 13 Proposal Denied ❑
In oector's 816n ture & TI le D to E iration Oate
Repair or000sal is in compliance with applicable codes Yes ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION- GFEN VI-RONM-F,,N'I'A-Lr -HEAT-Elf 'S ERV-1-C-ES---,`-----;-
FIELD ACTIVITY REPORT
A DDR E-Q, S:
Street Town State zip
PERSON IN CHARGE
nR TNT'FTZVT'F.WF-T-)-.
Name and Title
TYPE OF FACILITY:
FINDINGS:
TNqP'F.CTOR, TFT
Signature and Title
RFPQ'RT RFCFTVE-D'RY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
PUTNA_yt COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET -7 SUBSURFACE SEWAGE. TREATNLENT SYSTELI
Owner: % F2 L. l N Address: 3% 13�o0� <Sl 17� �il,
5
Located at (street): TM # Section: Block Lot
Municipality: P41TA-1AM VWuIy Watershed:. 1410Z)s®
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
Found
surface
(inches)
Start -Stop
Water
level drop
in niches
Percolation
Rate
min/inch
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Notes:
1. Tesrs to be repeated at same depth until approximately -qual percolation rates are
_L -'.__J -. - - -L ___. -.I_.: .._ .__. L -1- /: - i t -.- C -_ 1 -/) . -'_ •' I , I -
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DERTH HOLE # I HOLE #P HOLE # HOLE # HOLE
G. L.
0.5'
1.0,
2.0'
3.0'
3.5'
4.0
4.3 Crave-1
5.0.
7.0'
7.5'
8.5,
9.01
9.51
10.01
Indicate level at which groundwater is encountered
Indicate Level at which mottlina is observed /jC,/1./4_
Indicate Level to which water level rises after being encountered
Deep hole observations made by:
e el A/. Date 41147
_77
Design Professional Name:
Address:
451% j Olt
Signature:
V —p. r k
YES
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SITE LOCATION
OWNER'S NAME
MAILING ADDRE
APPLICANT
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
. IBC L
9-9101,4001,
N Internal Use Only PERMIT-# C7V`J'_
Repair Permit issued in last 5 years ❑ of in Watershed
Repair within Boyd's Comers, W. Branch or Croton Falls Res. 9 Delegated
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
:3q bP- aek.;j k7p 4VrOWN VvToo+p V4Gc�r TM # 'qt t' I S- I —.S
,4LA-I(k 2,A -w2De_A-(-1 H PHONE #qly Zed V.5k_3
v� -ki4ba �dA-Lt..i?y hli'f, �d�'i �+�� -rk6 t3(toek �1ri��
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE j PCHD COMPLAINT #
PROPOSED INSTALLER �w 4r`f _�� 3ir
�+� r4� � f�-r� � Fes?' PHONE # s,
ADDRESS P--P REGISTRATION /LICENSE # In SF 3
to_T47
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.
S
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1, as owner,agree to the conditions stated on this form
SIGNATURE TITLE�ti DATE D
(owner)
_....._.I,..the,septic inst Iler, agree to comply with the conditions of this permit for the septic system repair - • -
SIGNATURE TITLE #46 k? DATE ly O
(installer)
Proposal approved 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 Lir Proposal Denied ❑
Z4�L�� A--) i Ka4Z -5k— E 4 - '9 G 0 2
'Inspector's Signature Signature & itle Datb Expiration Date
I.Repair proposal is in compliance with applicable codes Yes ❑ No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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"LORETTA MOLNARI R.N:; - 1q.S.N:
Acting Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Frank & Patricia Zamperlin
39 Brookside Ave.
Putnam Valley, NY 10579
Dear Mr. & Mrs. Zamperlin:
April 23, 2003
ROBERT J. BONDI
County Executive
Re:Addition- Zamperlin, 39 Brookside Ave.
No Increases in Number of Bedrooms
(T)Putnam Valley, TM #41.15 -1 -5
I have received and reviewed the plans for the proposed addition to the above - mentioned residence.
The proposal for the addition has been approved as per plans bearing the approval stamp from this
Department dated July 31, 2003 The addition is approved with the following conditions:
1: The total number of bedrooms must remain at three. without prior-approval bythis
department.
2. The area of the existing sewage disposal system, and its expansion area, must be
maintained.
3. All plumbing fixtures must be updated with water saving devices, i.e., new low
flush toilets, restrictors for shower heads and faucets, etc.
Any other permits or variances required are the responsibility of the applicant and the jurisdiction of
the Town of Putnam Valley.
If you have any questions, please contact me at your convenience.
WH:lm
cc:BI (T)
Very truly yours,
i
William Hed s
Senior Public Health Sanitarian
Public Health Director
LORETTA MOLINARI KN., M.S.N.
Associate Public Health, Director
Director of Patient Services
DEPARTMENT, OF HEALTH
I Geneva Road
Brewster, New York 10509
Environinental Health (845)278-'6130 • Fax(845)278-7921
Nursing Services (845)278-6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014' Preschool (845) 278-6082 Fax (845) 278 - 6648.'
ADDITION APPLICATION (RESIDENTIAL QnM
o
STREET &OoKSiDe Ave. TOWN _RTj4AM VAUgqrx MAP# 'H 1. 15 - I -S
NANIEE6WK 8,40 -PATR-1 QR PHONE 3A;i�g�-3 1.6 PCHD9 A,-z--co
7_AMP09LIN
MAILIN`G.ADDRESS aq -b,A00"1DF- AtE PwrlJAM 10;5-79
DESCRIPTION OF ADDITION ER&&_b!L8r dCCe,5,5
NUMBER OF EXISTING BEDPOOMS
A OF BEDROOMS
(FROM CERT. OF OCCUPANCY OR blnoorns,jasf
CERTIFICATION FROM BUILDING -INSPECTOR)
2 ofl
*Any addition which is considered a bedroom requires formal approvif'6f plans (Construction Permit)
prepared by a Professional Engineer or Registered Architect in accordance'With applicable sections of the
Putnam County Sanitary Code.
Please submit this form and the following to Putnam County Health Dtpt;', 4 Geneva Road, Brewster, NY
NV10 09, Phone 278-6130.
Certified check or money order for $100.00..
Sketches of existing floor plan (drawn to scale, all living area including basement)
*Non-professional sketches are acceptable.
Two sets of proposed floor plan (drawn to scale, with name, street, and tax map 9)
*Non-professional sketches are acceptable.
Copy of survey showing well and septic location, to the best of your knowledge. Include date of
installation istallation if known. Label,all wells and septic systems within 200 feet of the property line.
Contapt this office with any questions.
Copy of Cert. Of Occupancy from Town or Certification frorli Building Dept. with legal bedroom
count of dhelling,
OFFICE USE
Comments
Feb98
Whouseguidelines
BRUCE R FOLEY
».P:LOR,ET'TA M01,11NiAM. L,K..' � Iv�9 i i . ... .. .
Associate Public Health Director
Director of Patient Services
DEPARTMENT. OF HEALTH
I Geneva Road
Brewster, New York 10509
Environmental Healthf (843) 278 - 6130 Fax (84S) 278 - 7921
Nursing Serviees (845)2711-6558 WIC (US)278-6678 Fax (84S) 278 - 6085
Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
Re: ZAWVWJV
Residenct
Tax Ma AU Town w. (,
Gentlemen:
According to records maintained by the Town, the above noted dwelling
IS
in compliance with Town code and the total number of bedrooms on record is
This information has been obtained from:
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD:
BFhouseguidelines
Building Inspector
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