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02651
BRUCE R. FOLEY
Public, ffealrh -Director -
..... . _ .= ..
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
LORETTA MOLINARI-
ifsso`ciale 4_ -kFc &aA Director
Director of Patient Services
Environmental 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 - 664
/ 2 a�
ADDITION APPLICATION (RESIDENTIAL_ ONLY)
STREET 960 Peo se_l LL 00 LLDW 9D-TO' V Pr _TX MAPm -SQ -3
7
Nk%, E�'t eisTo�HE� ��M HONEP�'s S.-2G -a363 PCHDTM A-dj--m
,vLkm \G ADDRESS 760 PF&_SKIGC. 4LwtO AA' �u M U tLVik /U
/os�9
DESCRIPTION OF ADDITION APO yAPoIJ V- A-DD/N C, a ")d '0:z®Ur
\TUMBER OF EXISTING BEDROOMS / PROPOSED # OF BEDROOMS
(FROM CERT. OF OCCUPANCY OR
CERTIFICATION FROM BUILDING INSPECTOR)
*Any addition which is considered a bedroom requires formal approval of plans (Construction Permit)
prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the
Putnam County Sanitary Code.
')lease submit this forn, and the following to- Putnam County'Health Dept.,'4 Geneva Road, Brewster, NY
10509, Phone 278 -6130. y'
1. Certified check or money order for $100.00.
2. Sketches of existing floor plan (drawn to scale, all living area including basement)
*Non - professional sketches are acceptable.
3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map 4)
*Non - professional sketches are acceptable.
4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of
installation if known. Label all wells and septic systems within 200 feet of the property line.
Contact this office with any questions.
5. Copy of Cert. Of Occupancy from Town or Certification from Building Dept. with legal bedroom
count of dwelling.
OFFICE USE
Continents
Feb98
BFhouseagmdelines
BRUCE R. FOLEY LORETTA MOLINARI R.N., M.S_.N.
Public Health Director Associate Public Health Director...
Director of Patient Services
DEPARTN EENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845)278-6130 Faz (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
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
Gentlemen:
Re: 7& D
Residence
Tax Map
Town ��.(�,
According to records maintained by the Town, the above noted dwelling
IS t�
IS NOT
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.
OTHER
BFhouseguidelines
�uildlng Inspe for
Christopher R. Campo
760< Peekskill Hollow ,oadw:.:_....
Putnam Valley, NY 10579
(845) 526 -2363 — (914) 767 -6135
CHRISTOPHER.CAMPO@PEPSI.COM
EIGHTY- EIGHT@PRODIGY.NET
Mr. William Hedges
Senior Public Health Sanitarian
Putnam County Department of Health
Division of Environmental Health Services
4 Geneva Road
Brewster, NY 10509
January 28, 2002
Dear Mr. Hedges:
Regarding proposed renovations at 760 Peekskill Hollow Road, please find the requested
documentation enclosed.
I current own a single -story residence at this address and would like to make renovations
enlarging the house to a two -story four bedroom home. This will require a new septic system, as
the current system is only satisfactory for a one bedroom home. At present, there is a 500 gallon
tank (indicated on the survey), but I do not know exactly where the septic fields are. With your
approval, I will contract an engineer to design and test for the new system.
Please feel Tee to coniact me, if you would like to make an appointment to inspect the property.
Thank you for your time, attention and rapid response to this request.
Sincerel ,
Christopher . Campo
r
i'
Encl: Money Order for $10. /.00 made payable to The Putnam County Health Department
Completed Residential Addition Application
Photocopy of the Letter of Compliance
Sketches of the existing floor plan
Two copies of the proposed floor plans
Copy of current survey with wells marked
IDUTNAM COUNTY DEPARTMENT OF HEALTH
DI SIOi OE E �'IROtNNIENTAL HEALTH -SE VICES
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # �/���j� ->`c8�
Located at %/,o Aa %%C''1�, wn or Village ,P:v
Owner /Applicant Name. C4'!� / //�Ot/" Oa ?P Tax Map c�" -z Block 3 Lot 77
u
Formerly
Subdivision Name
/ Subd. Lot #
Mailing Address 7 Xv
Date Construction Permit Issued by PCHD
Separate Sewerage Systems built by 11v q<7--r2 6 ,? Address d'd le�
Consisting of Gallon Septic Tank and -V�O 9 —4
Other Requirements:
Water Supply: . Public Supply From
Address
or: l' Private Supply Drilled by "'5;t %�i�J Address
Building Type �� / C-'C' Has erosion control been completed?
Number of Bedrooms Has garbage grinder been installed?
AIR
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Department of Health.
Date: Certified by of NEty E. R. A.
�� � C f � (Design Professional)
Address l� ��� rare- i
Any personbccupym�J g premises served�j the above s tem(s) shall pro u t c as may be necessary
to secure the correction of any unsanitary conditions esulting from such of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer' 'bee es available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals are subject' to modification or change when, in the judgment of the Public Health Director, such
revocation, modification or change is necessary.
By: �'"� Title: Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Profess'onal
Form CC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
7Z
ZZ.
Own;;r or Purchaser of Building Tax Map Bl(,:-k Lot
Building Constructed by Tow-nNillage
Location - Street Subdivision Name
Building Type ,.jbdivision Loy #
I represent that I am wholly at-iJ coinplct�,Jy responsibl.c for he location, w;:)rkmanship,;materia,
consiruction and drainage of the sewage treatment s'VSWM Ig the above-de .cribed property, at.: I
that Is has been constructed as shown on LI-It approved pi,,,in or approved amendment thereto, k-,nd 2 n
accordance with the standards, rales and rt-U.1ations of the Putnam County Department of Ht;alth, ar;.LJ
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating corgi .tor:
any part of said system constructed by me which fails te. operate for a period of tV-0
irnmedi ately -following the date of apprgy-al of the - "Certificate of Construction Compliance'.'for the
sewage treatment system, or any repairs made by me to such system, except where th.6failurc to
operate pf6oerly'is caused by the willful ot-negligent act of tlie, occupant-o € the buildingutifiz}nglte
system.
The undersigned further agrees to accept as conclusive the determination of the Public Healti.,
Director 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 utilizing the
systcrn.
Dated;/ Month Day � Year
(3eg,zral Contractor (Owner) Aignature
Awaod 6,�e!yr
Corporation Name (if corporation)
1 Ell
Title: 0 Wn ey--
Corporation Name (if corporation)
d d re s s'-
.State a Z
ip
.,Fozm OS;97
DIVISION OF ENVIRONMENTAL HEAL'T'H SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM 5'
PERMIT # djj- en
Aq 3 - 0.
Located at!!
Town or Village,,, y Yto Ile-
Subdivision name
Subd. Lot #
Tax Map J-2- Block 3 Lot 7,
Date Subdivision Approved
Renewal Revision
Owner /Applicant Name . C%,-:S Cam,-,, v Date of Previous Approval
Mailing Address 7lv e z-�Ie = `& , //. L/ Zip /obi
Amount of Fee Enclosed /61
Building Type jyej &-e Lot Area 3. !2 No. of Bedrooms Design Flow GPD e,,p cs
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of / 2S'e/ gallon septic tank and �cr
Other Requirements:
To be constructed by Address
Waterer Sup"I Public Supply From Address
or: Private Supply Drilled by Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatmentsystem described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed: s �` R.A. Date
Address 2 9 7z License # a 4 y
APPROVEII'FOR CO ISTRUCTIO 1 This anor va DIi l oyve' ` om the date issued unless construction of the
sewage treatment system has been completed and inspected, b.X t'&dPET D °Wand is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director: "Any revision or alteration of the approved plan requires
a new permit. Approved;for discharge of domestic sanitary sewage only.
By: ® _ Title: -�`t- �i� Date: G ��
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design rofessional
Form CP -97
PUT NA r
P�J .�. N.A.M.• COT. NTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DIVSIGN DATA SHE &'_ S BSWJ FACE SEWAGE TREATMENT SYSTEM
Owner c' /_,a ir,�_. Address %d t�����J�ff /�`'�'1 %� v�
Located at (Street) �,& ml,,OV Tax Map�.2 Block Lot
(indicate nearest cross street)
Municipality %a�� /�+ Watershed
Date of Pre- soaking _ d
SOIL PERCOLATION TEST DATA
z�G Date of'Percolation Test �— l
f
::.:.. .
No.
-777
T�9au.1N1v
.:77..... :.. .
Depth to water:;:.. Water• .. :. .`• <� ; .
From Ground :Level ercoit:
<::::T, tae . .. �,la se Time Surface (Inches) .. .. rQ In.
� #ari Sto (pMin.) Start Stop. :�nc�es i�1�l�C�A
p:. .
-
1
3 0 _5 % �.
S Z> Ze
2
g5/ 12 2.1 -7
4
a
1
.
2
_ ...._ :. _..
3
4
5
2
3
4
5
'
NOTIE S:'-'— 1. Tests to he repeated at same depth until approxima-.'ely equal percolation rates are obtained at each
percolation test hole. -(i.e. s I min for 1 -30 min/inch, s 2 min for 31 -60 minlineh) All data to bo
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD-T)
Indicate level at which .groundwater is encountered,
Indicate level at which mottling is observed
Incicate .level to which water level rises after being encountered
Deep dole observations made by: Date z-
L)es,D, Professional Name: o�� y, ��ar vat
Address: - -- 7 ' ✓ � C r
Signature:
Design Professional's Seal
15
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TEST PIT DATA 2
DESCRIPTION OF SOILS
ENCOUNTERED IN TEST HOLES
D l? "l'1I
HOLE NO.
HOLE NO.—,5 HOLE N0.
for,
_ 216a
/ 'e >1
0.5'
1.5''�
—
-
2,5'
3.0'
—
3.5'
4.0'
5.0'
5.5'
6.0'
—
6.5'
--
7.5'
8.5
9.0'
10.0'
Indicate level at which .groundwater is encountered,
Indicate level at which mottling is observed
Incicate .level to which water level rises after being encountered
Deep dole observations made by: Date z-
L)es,D, Professional Name: o�� y, ��ar vat
Address: - -- 7 ' ✓ � C r
Signature:
Design Professional's Seal
15
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
RE: Property of
LETTER OF AUTHORIZATION
Located at ,Ze., ��/�i�i A /�`��� �oa
TNV"�' 1Q. ��� Tax Map # J2 Block Lot %7
Subdivision of
Subdivision Lot #
Gentlemen: '
This letter is to authorize de;'ePj
Filed Map #
' v % /J` k-o "�'
Date Filed
a duly licensed Professional Engineer l-*"'or Registered Architect to apply for the required
vastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater tretment and/or water supply systems in
:tonforrnity °.with.the provis ons.of Article 145 and/or .147,of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code.
/State JI/ Zip
selephone: Ye�� y
Very truAof Signed(Owner Property)
Mailing Address: /ZU
State 7i' ' Zip
Telephone:
Form LA -97
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