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73.05-2-37
BOX 27
03346
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03346
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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YES NO Internal Use Only PERMIT # - [X4
❑ Repair Permit issued in last 5 years Not in Watershed
❑ ,--�/ Repair within Boyd's Comers, W. Branch or Croton Falls Res. El Delegated
El LJ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION ' 9' 4001 <00f f *9
OWNER'S NAME
MAILING ADDRESS
TOWN Pl"/4,M ( ";, • ,TM # 3• °� ���
PHONE #
APPLICANT p Y1/ jY
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE �� �.�'AA6yPCHD COMPLAINT # _
PROPOSED INSTALLER _1Jrp4 D LAM D pia & PHONE # 1014-2—
ADDRESS 05GAWAHA 1)161411 11 1DAI TN tii )REGISTRATION /LICENSE # I lot L
� . a� sl
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 nf the renair 1• '' . r
I, as owner,agree to the conditions stated on this form
TITLE K ",S SIGNATURE DATE 1
(owner)
I, the septic installer, agree to comply with he conditions of this permit for the septic system repair
SIGNATURE TITLE LP DATE
(Installer)
Pro I aoDroved ' h thA folio- i 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
Prop al p r Pr p al Denied El P(- 2
NV
Inspector's Signature &Title
la
1I + Date Expiration Date
Repair proposal is in compliance with applicable codes Yes ox No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Putnam County (Department of health
Division of Environmental Health Services � 'r 0
SSTS Repair - Final Spection . .
Date: Inspected by: , 'U / Installer: 7Zo e- t
Street Locati n: Owner:
Town: Repair Permit Z - /,t TM # ? 3.0 - a�3
Additional Comments:
RFS1 Rev - 011312
e
1. Type of System: Conventional WAlternate 0 Comments:
2. Se tic Tank
Yes
No
N/A
Comments
a. . Septic tank size -1,000 ... 1,250... other .....
2
0
A f a+ 401-Ne*4,
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
d. Distribution Box "
i. All outlets at same elevation (water tested) .. .
H. Protected below frost .............. ................
iii. Minimum 2 ft. Original soil between box &
trenches
e. Junction Box - properly set ............................
f. Trenches
i. S stern completely opened for inspection
ii. Length required Length installed
�
iL 1Zok15 cd 1. ry
iii. Pie slope checked ...................................
iv. Installed according'to plan .....................
v. 10 ft. from property line - 20 ft - foundations ...
A
vi. Size of gravel 3/< - 1 '/Z " diameter clean .........
vii. Depth of gravel in trench 12" minimum .........
viii. Ends capped .... ...............................
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g. Pumg or Dosed Systems
3. Sewa e System Area
a. SSTS Area located as per approved plans
b. Fill section
c. Distance from water course /wetlands
4. Overall Workmanship
a. Boxes properly grouted and installed correctly ...........
b. All pipes flush with inside of box .........................
c. Backfill material contains stones <4" diameter .........
d. Curtain drain & standpipes installed according to plan
e. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
RFS1 Rev - 011312
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rgoPo560 5�P,114 12 ,Cn141R 1=� r�
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-T-NA , 73,.5-2-S?
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PUTNAM (COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
REQUEST FOR FIELD TESTING
All information must bed completed prior to any scheduling. Date:
Engineer or Firm: n
Iverson to Contact: e -�- '�=— �"`��—
❑ New Construction 18epair Program
Reason: ❑ Deeps ❑ Peres ❑ Pump Test
Phone M.
❑ Addition Program
(road /Stret: _ za�I'e—eO a-5�-5�. ��
Town: V Tax Map #:
Subdivision: Lot #:
Owner: _
❑ Project not within NYC Watershed.
NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING
YES NO
❑ ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner
reservoirs.
❑ ❑ Proposed SSTS within 500 feet of a reservoir,, reservoir stern or control lake.
❑ ❑ Proposed SETS within 200 feet of a watercourse or a (DEC wetland.
❑ ❑ Proposed SETS design flow greater than 1000 gallons/day or SPIDES Permit required.
❑ ❑ Proposed SSTS for a Commercial Project.
It is the responsibility of the design professional to provide the above information prior to soil testing.
This (Department will determine the NYCDEP project status (Joint or Delegated) based on the response.
if you answered yes to any of the questions, NYCDEP must witness the soil tests. This (Department will
coordinate a mutually suitable time for field testing with the Design Professions and NYCDEP.
If a project has been determined to be Delegated based on the above response and then subsequent
information indicates KYCDEP is required to witness the soil tests, it will be the sole responsibility of the
design professional to schedule re- witnessing of the soil testing with NYCDEP.
FOR COUNTY USE ONLY
DATE: TIME:
COMN[ENTS:
Req.for field testAly 4/16/2009
PUTINAM COQ NTY'6EkARTMENT OF HEALTH
DIEVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN IYATA SHEET - SUBSURFACE SEWAGE TREAT�i fENI T SYST'P-
Located at (street),
tyl unicipality:
?address: O LO'OL ��SS
13s 1 37
Tel 4 Section: Block Lot
Watershed: J �//4
SOIL'PERCOLATIOiv TEST DATA
Witnessed by:
pate of Pre- soakiipg: Date of Percol-atian Test:
Hole No.
Run No.
Time
Start —
Stop
El.ap.se
Time
(min.)
Depth to
water from
round
surface
(inches)
Start - Stop
Water Percolation
leveI.drop Rate
in inches min /inch
1
I
,
2
k
k
3
I
I
4 I
5
I
2
3
I
4
2
3
(
I
k
I
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ivores:
1. Tests to be mpeared at same depth until approximately equal. percolation races are
obf,ained At each percolarion rest. hole. (i.e., < l min for l -30 rntr /inch, < 2 min for 31 -50 min,' inch).
All data to be submitted for reviev.
2. Depth measurements to be made from top oF(tole.
Form DC-9 i.
TEST PIT DATA ,
DESCRIPTION OF SOILS ENCOUNTERED M TEST MOLES
DEPTH HOLE # HOLE # HOLE # HOLE # HOLE-#- -
G. L. _
0.5' 1.�.
1.0'
1.5
2.0' Loa PA
2.5'
3.0'
3.5'
4.0' `cY�• nn
4.5'
5.5'" Ra
6.0' lt�ec�
6.5'
7.0'
7.5'
8.0'
8.5
9.0'
9.5'
10.0'
Indicate level at which groundwater is encountered . Al ON 2
Indicate level at which mottling is observed not
Indicate level to which water level rises after being encountered
AIIA
Deep hole observations made by: Date 'L Z
Design Professional Name:
Address:
Signature:
Design Professional = Seal
BRUCE_ - R._..FOLEY
'�.:r`""`:.:`° urs" b� C " �t` ea lili'�.L��eClo`"r°".._;�,,,;:� r ::..;. � :.:�.•.,..,.::�:� :.�
MOLINARI R.N.. - ASS N -
• wOr/ S�. i +:�A�..- T.aA�+/L.i.�.'.wgk..-.. :. .�...4I1 'iV- ir.+4A'{'n�w'M�
Associate ublic Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York . 10509
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 .Preschool (914) 278 -6082 Fax (914) 278 - 6648
May 5, 2000
Thomas VanDeveerdonk
8 Lookout Pass
Putnam Valley NY
Re: Addition- VanDeveerdonk- 8 Lookout Pass
No Increases in Number of Bedrooms
(T) Putnam Valley Tax # 73.5 -2 -37
Dear Mr. VanDeveerdonk:
a
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 form this. Department dated May 5, 2000 .The addition is approved with the following
conditions:
1. The total number of bedrooms must remain at Three without prior approval by
this department.
I'.',...';.1
- an;, �±2 extfian;L;.vol..-
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.
Very truly yours,
William Hedges
WH:kg Senior Public Health Sanitarian
cc: BI
a S
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
TK (914) 278 - 6130 Fc (914) 218.7921
PROPOSED ADDITIO \T APPLICATION
STREET Lora i4cv`T PASS
BRUCE R. FOLEY
Public Health Director
(RESIDENTIAL ONLY)
PUTNA t�lr
TO��'i� V 4'4 t: � TX XUP # ��� S' - Z — ??
T140 A&S VA. 0 DV-' VEE0-po+-1 K-
NAME HONrE E528 3605- PCHD
MAILL�TG ADDRESSS l,..vot-ov tr pA Ss , Pcl -r-J A K-A— vAL -L-5c(
DESCRIPTION OF ADDITION lot K t y e0►. -'c STY A DDI-ito0 Ta t Fe 2 or—Fk
NIUMBER OF EXISTING BEDROOINIS PROPOSED ;r OF BEDROOMS 3
(FR0�1 CERT. OF OCCUPANCY OR
CERTIFICATION FROM BUILDENG NSPECTOR)
*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
4pplicable.:sectl9nS
Please submit this form and the following to Putnam County Health Dept., 4 Genevand.,
Brewster, NY 1009, Phone 278 -6130.
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 ofproposed floor plan (drawn to scale, with name, street, and tax map 9)
* 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.
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OFFICE USE
Comments
Feb 98
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