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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITIONIREPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project S .� 3 l -�-� ��v�� 'L1�'mm TM#
Year of Construction 1161 Size of Parcel s
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. 17 HY ❑Rolling (7 ee P SloP e ❑entle Slope ❑Flat
2. ❑Evidence of wetland ❑Low area subject to flooding ❑Bodies of water
❑Drainage ditches Mock outcrop
YES NO
3. Property lines evident? ❑
4. Water courses exist on, or adjacent to parcel:
5. Existing individual wells within 200ft of the existing SSTS? �/ ❑
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. []Level UGentle Slope ❑Stee P slope
�
B. ❑Well drained DI / oderately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited DSomewhat limited ❑Adequate ft x ft
D. INSPECTION Date Inspector
LNo evidence of failure DEvidenceoffailure ®Evidence of seasonal failure
'y
-------------------------- - - - - -- -----=----=-------------------------------------------------
(Indicate North)
HOUSE
I�!
(1) Indicate location of SSTS .
A. Size and type of septic tank gallons
0Metal OConcrete CIPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallies ft.
y- - - -
k'2'- indicate setbacks; front street, backyard, and side yard dimensions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
to
SECTION E. EXISTING WATER SUPPLY
11PWS OShared well L�Individual well
r1rilled ODug [lasing abo.ve ground
COMMENTS
REPAIRS ONLY: Status:
P
As Built Inspection Required: As Built Submitted:
As Built Inspection Done: Inspector:
a
t 67 X
Dear Mr. Luke,
I am in the process of obtaining a CO for an addition on my home of 25 years and John
Mahoney of the Putnam Valley Building Inspectors office suggested I contact you
directly. I have phoned a few times at the number he gave, but you were out of the office
on business. In speaking to Mr. Marvin Odell, he also recommended I send in floor plan
to you for the small addition to the rear of the house. I hope the enclosed drawings will
suffice to assist me in obtaining the proper permits from your office so Mr. Odell can
give me the CO. I would appreciate any assistance you can give me in this matter.
Please advise me if there are any fees involved.
Mr. Rush, a local builder who constructed a number of homes along Peekskill Hollow
Road, installed the original septic fields and 750- gallon tank. In addition, I have enclosed
a copy of my survey with the new addition drawn on the rear of the house. The room will
serve short time as a bedroom, but mostly a computer workroom. We are a family of
three.
Please'let me know if there is anything else you require.
t re ,
rt Campo
523 Peekskill Hollow Road
Putnam Valley, N.Y. 10579
Telephone 914 528 0775
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PARCEL SHOWN HEREON SURVEYED IN ACCORDANCE
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SURVEYED AS IN POSSESSION ( No Linn of Possession NOT STAKED