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62.15 -1 -44
BOX 24
02915
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION.OF ENVIRONMENTAL HEALTH SERVICES �0E)IT,-11 L
PROPOSAL FOR SEWAGE TREATMENT-SYSTEM REPAIR.. �-�
NO Internal Use Oniv PERMIT #
❑ Repair Permit issued in last 5 years of in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Z Delegated
❑ 9�Repajr within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 30 S! a *11R TOWN 4/6 GTM #
OWNER'S NAME
MAILING ADDRESS
APPLICANT Z. • G/
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4w.rf.
Name & Relationship (i.e., owner, tenant contrac 1�
DATE i %� FACILITY PE iP PCHD COMPLAINT #
y�
PROPOSED INSTALLER uJ -F 464 r✓J� PHONE #
ADDRESS �i �ar ,t �/ REGISTRATION /LICENSE #
Proposal (include a separate sketch locating tfie house, property lines, all adjacent wells within 200 e
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. -) D _ _ _ % , /; _ _
I, as o er,agree to the onditions. stated' on this form
dj
SIGNATURE 0-i 1I v � `' TITLE DATE
(owner) _
±iC_inciallcr u to Cnrrt�l� it he conditirns C4 seprir_. SyC!Frr. re
SIGNATURE TITLE �e1�� DATE /
(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 backfill until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal pproved 2 Proposal Denied ❑
Insp ctor's Signature & Title Date Ex ration Date
Repair DroDosal is in compliance with applicable codes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
May 10 12 10:22a
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PUTNAM COUNTY DEPARTMENT OF HEALTH
FIELD ACTIVITY REPORT
NAME• 1�1 nerfe� Tel.
..- .r..r,,,. ter, c _ _ . •,� �J � / . , .i ... _ t v�
Street Town ® State Zip
PERSON IN CHARGE
I—Y-zv4 [ y5 5 /
Name and Title
TYPE OF FACILITY : Sh u�, I ,�_ rr ��
FINDINGS:
TNSPFCT_ (1R -_� E 1 � � TFT -
Signature and Title
RFPCIRT RF.C..F.TVFT) BY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
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SCALE: /" = 30'
Unauthorized alteration or-addition to a surve .t;ear-
ing a licensed land surveyor's seal is a violatlorot section
7209, sub div.i,slon 2. of the New York State Ed'u'?hon
The loca underground improvs�►ents c
encroachm exist. are not ^ertiliea{
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May 02 12 10:44a RUSH
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Drywells
Ilia
**414* 110
630 Gallon 157"
18455261958 p,2
H dson Concrete Products
3504 Route 9
C f d Spring NY 10516
(845) 265 -3265
Height Inlet Price
3'8" 34"
t;ommerqiai1JrVW
;:iii Kin
r Height
Inlet Price
Diame
315 on
.4'
4'
41"
650 Gallo
B'
2'
12"
1300 Gallon
8'
4'
36"
2200 Gallon
0'
4'
36"
Roof Slab
4
6"
Roof Slab
Roof Slag
10'
"
Gallies
Heigh
- Trl- Ga1'ies..:. 26"
4x4 Gailles 52"
All Gallies are equip Ij, v�d
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elf
10600 : 6im'l e
P.00% 1111
1�rjqj K
Se.11.41
'Pr4i .
� S Ow low
$485.00
$585.00
$71 0.00
$475.00
$460.00
$635.00
$810.00
$105.00
$410.00
$510.00
Le inlet Price
ooW. V 48" 8 314 ". $210.00
Hangers
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Call for pricing
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LORETTA MOLINARI
Public Health Director
_ -z
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 Interventlon/Presebool (845) 278 - 6014 Fax (845) 278 - 6648
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
December 20, 2004
Dear Mr. Anderson:
ROBERT J. BONDI
County Executive
Re: Proposed Well Kneuer
30 Sawmill Road
(T) Putnam Valley
62.15 -1-44
A field inspection was conducted on the above referenced lot by Brian Stevens, Public
Health Technician. The application to replace the existing well is approved with the
1. As noted in the plan submitted to this Department, the well casing is to be 80 feet
in depth.
2. The existing well is to be abandoned once the new well construction is complete.
Please provide notice to this Department five days prior to abandoning the existing
well so that this Department may witness it.
A Well Completion Report (WC -97) shall be submitted no later than 30 days after the
well completion by the permittee.
Please contact the writer at (845) 278 -6130 ext.2235 if you have any questions.
Sincerely,
Brian R. Stevens
Public Health Technician
cc: RM, file
A. PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_ -
APPLICATION TO ABANDON A WATER WEL.I.
please print or type
PCHD PERMIT # UJ V-5—()V
Well Location:
Street Address wnNillag Tax Grid #
Block Lot(s)
Map
Well Owner:
Name:
Address:
Well 'Type:
Drilled Driven Dug Gravel
Other
Depth Data:
Well Depth ft
Tatic Water Level ft TDate
Measured
Use of Well:
><- Residential Public Supply Air /Cond/Heat Pump Abandoned
I- primary
Business Farm Test/Observation Other (specify)
2- secondary
Industrial Institutional Standby
Water Well
ame: Address:
Contractor:,
Reason For
Abandonment:
Description of Work To Be
Performed:
Date:
Applicant
PERMIT
This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR
and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a certified statement that tFiation delineated on the application for this
permit has been completed.
12--WOV i
Date of Iss e
Permit Issuing Official
Title
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97
Z�'
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��-99�77S�
PUTNAM COUNTY DEPARTMENT OF HEALT
DIVISION OF ENVIRONMENTAL HEALTH SERVICE
please print or type PCHD Permit # vtl%
Well Location:
Stre ddress: illa � Tax Grid #
/'lock
Map )-. • Lot(s)
Well Owner:
Name:
Address: I
V6
Use of Well:
X' Residential Public Supply Air /Cond/Heat Pump Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought gpm # People Served - Est. of Daily Usage e4gal.
Reason for
? ff Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
-,�► -'
for Drilling
Well Type
Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No ><
Is well located in a realty subdivision? ...................................... ............................... Yes No -><
Name of subdivision Lot No.
Water Well Contractor: Address: ✓
Is Public Water Supply available to site? ................................. ............................... Yes No k
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Ale
Date: d Applic'arif Signature��1
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and 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 or their designated
representative 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. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and 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.
APPROVED _FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water ell ller c led by Putnam
County.
Date of Issue ;+`fir `' �' A Permit Issui fficial:
Date of Expiration (, 6- Title:
Permit is Non -Trans er ble
White copy - HD file; Yellow copy - Building Inspector; Pink copy - own er; Orange copy - Well driller
Form WP -97
=x
DEPARTMENT OF HEALTH
Division Of Environmental . Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
September 24, 1991
Mr. Paul Kostuk
238 Peekskill Hollow Road
Putnam Valley, NY 10579
Re: Residence destroyed by fire
Ruth Lent
Mill Road
(T) Putnam Valley TM 62.5- 15 -1 -44
Dear Mr. Kostuk:
JOHN KARELL Jr., P.E., M.S.
Public Health Director
I have received, reviewed and hereby approve the plans for the reconstruction of the above
mentioned residence destroyed by fire.
?ermits to rebuild residence destroyed by fire or other natural cause are issued by the
Lndividual Town building inspector and in some cases require variances issued by the Zoning
3oard of Appeals. The Health Department reviews only the water supply and sewage disposal
system for the residence. If the residence is served by an individual well and sewage
iisposal system which was functioning before the residence was damaged, this Department has no
)bjection to their continued use with the following conditions.
0 The new residence must be constructed generally within the existing footprint if possible.
:) The total square footage-of the new dwelling must be equal to or less than the original.
structure. The plans indicate totial square iodtage wiil "increase by approximately 15k bi*
the original structure. Based on the area available for future sewage disposal, this
Department has no objection to this increase.
:) The total number of bedrooms or potential bedrooms must be equal to or less than the
original structure. The plans indicate the original dwelling contains five.bedrooms.
fur approval is for the use of existing sewage disposal system and water supplies only. Any
,ther permits or variances required are the responsibility of the applicant and jurisdiction
,f the individual town.
f you have any questions, please contact me at your convenience.
Very truly yours,
John Karell, Jr., P. E. ~f
Public Health Director
K/jp
JK, File, WH
BI (T) Putnam Valley
4�
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Ccamnissioner of Health - FIELD ACTIVITY REPORT -
ADDRESS
No. Street Town IM No.
MAILING ADDRESS
P.O. Box Post Office Zip Code
PERSON IN CHARGE / /�' OR INTERVIEWED � � G.,.,,� �
Name and Title
DATE YPE FACILITY
TIME ARRIVED 7 TIME LEFT
Sheet of
PECTION
Orig. Routine
Orig. Complain
Orig. Request
Compliance
Complaint Comp
_ Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other-.
Explain
FINDINGS:
y��a {qf/'/ µ, �`/ off
i may / '^ C '!C ..® a ! �J6rJ' '7 / �..
INSPECTOR:
TELEPHONE:
Signature and Title
PERSON IN CHARGE OR II�FTERVIE,TnTED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE: