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HomeMy WebLinkAbout3346DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05-2-37 BOX 27 03346 It J a 'ti m IN OL 03346 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ��� �Q ✓�,��0 7 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 .... ............................... ol 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 e Qw IU fJ )21 6 rgoPo560 5�P,114 12 ,Cn141R 1=� r� 1'1�nMl�s ✓'� ti� n� V�CrL �v� i< �?Gc�o%�c�r�i pyss -- �t�TNl�M ®_ A R � _ 1 N FiL�Ria>"o�5, r"5150 — �6Nt Y iq6pv -T-NA , 73,.5-2-S? r/ J l� � zt- 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 ,5. � I l k i r I I I - J 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. e OFFICE USE Comments Feb 98 LOOKOUT k:, 7 Me 6W7,0,; 104 I St.. New H Ii fvOV-.AA ATIOP -fF-rT,0AA 4. -CrA I I � -... At p y - �l ; 4. Loov-OUT FA6, S S rx AVCPIT(0141; AP4P A(--rrwrZA—.joj64S TO r_SSjr>C-hjCer M R. Mrs. T. VoN Ps VeErz voN v- SP -IA -X I spoe I n In 5i PE F O-M.m - A, T 140 P 40-mlo AA. A . V*gl D-A Ul rx AVCPIT(0141; AP4P A(--rrwrZA—.joj64S TO r_SSjr>C-hjCer M R. Mrs. T. VoN Ps VeErz voN v- SP -IA 0 U 1.64' 1 ;2 W)TOO 'Lo' e & —jr fz,2&3.00 NEW CA IST r bftA&e g rter.w.6 kw ts sry b 0 5r sTopf 20 j4 0. 41 ao�er I 1- :ME. a., Apse.—, -NOW WD pez" t-, Nr o ftl I'Lne T 5- F. L, -z P r-- 0 D r> F. 4, A NJ :9 IT .E- t"i=am"A-riaw przaAA A A-DC>rTIOtJS, AND ALTFrI-A7u9tJS SIP WC16 5-u(tv EF-r -f 13 a W'j F- y -CIAT LOCI: r 41'a T. Vs P De V �.oOK.ouT PASS, P U -T >j A M v A, L a Y tn G DJi i P_Ro.1.7 15. .o .� oI O t-►. JP f i 1 UTNAM U JiY DEPARTMENT OF M9M Y HOUSE PLANS P ROVED FOR BEDROOM COU T ONLY, BEDRO ' AEG Signature b Title Date I1 G�• I + D t i 1 4p —1 lV�tzg1�('S'T.NgDEVgg DON ; _ - LOO Y. 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