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HomeMy WebLinkAbout3367DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 73.08 -1 -6 BOX 27 1 ru him 16 1 �� 6 �r y - ;ii io • 03367 SHERLITA AMLER, MD, MS, FAAP "Commissioner of Health ... �_" ``.�,iFt�;'i "1•�►•lvltiL[iYARI, Rl�i,'MSIV . .. -4�.� Associate Commissioner of Health ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York •10509 ADDITION APPLICATION RESIDENTIAL ONL Y STREET 7-i/ioz, d TOWN ",g TAX MAP # " NAME , HON 49q PCHD# . _. -.0 MAILING ADDRESS DESCRIPTION OF ADDITION r_�ts /i NUMBER OF EXISTING BEDROOMS* : PROPOSED # OF BEDROOMS 3 (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. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 - 6130. 1. Certified check or money order for $100.00. 2: Sketches of existing floor elan (drawn to.scahe all.living area including ba`c:a:en:,_`r,hz,., a shu ^ and-d e� lsz ied and, u* a of ea "cii `room'specitied). (See Section 3.c of Bulletin HA -1) 3. Two sets of proposed floor plans (drawn to scale — with name, street and tax map #) * Non- professional sketches are acceptable and preferred. (See Section 3.d of Bulletin HA -1) 4. Copy of survey showing all well and septic locations on the subject property to the best of your knowledge. Include date of installation known. Contact this office with any questions. 5. .Copy of Certificate of Occupancy from, the Town or Certification from the Building Department with legal bedroom count of dwelling: OFFICE USE COMMENTS 5. Environmental. Health (845) 278 -6130 Fax (845)278-792.1 Water Supply Section (845) 225 -5186 . Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 s ` SHERLITA- AMLER, MD; MS, MAP Commissioner. of Health cA�z+R -T9 j�RraY sn �.D►. 7 fl T /1 • y � - ' -�..,. 1:11 . - 3 -$'- '� � �-.' -. -cam• - Associate Commissioner of Health ROBERT J. BONDI County Executive ., -.- - .•;� °, ..,_ , - - K(iisEitT NiARRI�,.I'E Director of Environmental Health DEPARTMENT OF HEALTH l Geneva Road. Brewster, New York 10509 Town Legal Bedroom Count & Proposed Addition Status Re: Henri i?kGOn. (Owner's Name) Tax Map #. � 3.8 -1- 6 Address: 19 Tyler -Rd. . Town: Putnam Valley -Year Built:. 1950 According to records maintained by the Town, the above noted dwelling, is . xx. in compliance with Town Code. )ts aen� in compliance with Town Code. The Legal Bedroom Count is: 3 This inform, ation has been -obtained from: �Certifcate,of'.Occupancy: CO #1965 -6503 & 1995 -84 Other: The plans for the proposed addition are considered: New Construction Addition to existing house -only Teardown• and/or re -build allowed under Town Regulations X1642 :...Buil....png Inspector. 6 Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (.845)225-5186 Fax (845) 225 -5418 Nursing.Services (845) 278 -6558 Fax (845) 278-6026 'Nursing Howe Care. Fax (845) •278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225-1580 SHERLITA AMLER, MD, MS, FAAP Commissioner ofHealth . ROBERT MORRIS, PE `�'�►�t Director of Environmental Health . 1 Geneva Road, .Brewster, New York 10509 Office (845) 808 -1390 Fax (845) 278 -7921 or (845) 808 -1937 July 5, 2011 Paul Hendrickson 19 Tyler Road Putnam Valley, NY 10579 Re: Addition- Approval - Hendrickson No Increase in Number of Bedrooms 19 Tyler Road (T) Putnam Valley, T.M. 73.8 -1 0 Dear Mr. Hendrickson: PAUL ELDREDGE County Executive - , -_ _. - _...._ _ , 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 from the Department - dated July 5, 201.1. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be 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. 4. The approval is for the proposed changes only. This approval does not validate any construction shown as existing that has not.obtained proper approvals. :AT, '. Qxl?e _neciTlitS- :,r'darii "��,' re u red -aue the. f� .....w. -�'.�1 _..�._ .�.....:r'z�p�,n�,;bil^�y o.��hc ppli�- a.n�x�t-the- of j�is�lii.�.;.. _ s ._�'..- ��..::_......-..._... -.. Town Putnam Valley. u m _ If you have any questions, please contact me at your convenience. S. Paravati, Jr., PE at Public Health Engineer JSP:cw cc: BI, (T) Putnam Valley ...dsi. E5 11 P '!'NAR1 CUiJNT 7�JAF4 fC M -ggFt4'bpj WAbt 11aN SE P .GANS APPROVED FOR BEDROOM COUNT ONLY. Irr:D}womrs 73 4- SUBS:b?UENT REVISION /ALTERATIONS TO THESE HU ti.5 ix�°,6ST BE SUBMITTED TO THE PCDOH FOR APPRd, j NAT UIZ E & TITLE .1 I q 7y l e -.r pAlltj M Vat eY K IM IRJLAWI'I.L TO MODIPY A DCX.UM4NT OEARING 1NB SEAL AND .AC4KW .= OI' A I.ICCN•5CD GNGINCCR. rXI5rCW6 AMA MOPIP ICA110N BF pis[; LP E VN19 Y PF-CK LLPs I pLL;'c'�p05�t7 r—LOOf2 FLAN [ NC '(E7 y DO NOf $LP2�[r. DRAWING • W al'r.N DIMENNOMi fAI:E ►+Pd_fGEDENGE. IN r.ACE OP DICCR21'iNCIB OR CONPI.ICt ;. NOTIPY DB SIGN PROPS S"_IONAL OZ U� 0 flfl > L — N S1 z R �` - iL S � DATL' : 14JUN Zni 54 ILer NO: 5-1.1 Ore,4 • 0 "1 x 2 1- xIll pS Z > Z z -k �ft -k i)z �Qp V () Z12 rn :< /M Z. rnp Z z Qrn N46'45'40 "W 15C 22 I z L< 1) � kD Sl "32 !) p =zl 0. Z 7� Z X_ 7 z 1'� m 7� L M > Z_ 4m Qrn C. V z M 4k r, ego ;3 COVF:- P-- 5H�F-f Z > Z z 19 TYLER I;zo^p rlrrNAAA VALLEY, NY �r Z -lz - --Z 7q z ;3 COVF:- P-- 5H�F-f Z > Z z 19 TYLER I;zo^p rlrrNAAA VALLEY, NY �r t Fl en Sr-,'c k co P4Ail';\, Oaft e �, 4� io3 7� IT 15 IJNLA\WLIL 1*0 MODIPY A DCX.IJM9NY OMARING TH2 5EAL. ANO %C4KW L= OP A L ICCNSCG CNGINCCR, t R 1-7'-0" I'ROr05ED AREA OE GHANGE - EX15T1N6 ( PATH TO PE RE MOVE D MA5fMP - DININCi l3E ROOM 5UNROOM ROOM d KITCHEN ? — x uttt Hill 11111 HALLWN(, BATH LIVING ROOM l3EI�ROOM Ci�'DROOM ` , r ENTRY DECK 1 ? 15 -rlNG r -cor, PLAN NOrE, DO NOf SGALr�OItAWtNG - WT2MtEN V1MEN510NS TAKE PM(:.eZ W.Z. IN CASE OP VtCGR�PM!CIEi 012 CONPL IC: i`i. NOTIPY tPV VrN PROPS llIONAL . Y •.1 �I OAF O O 74/ 4010 41- 73.8 r -, O Z L N� Z zp fl RL n z t- lu , t:7A-Pf<: 1.4JUN2CD11 51 IBt:T NO: 5-1.0 IiC { i � r i t Fl en Sr-,'c k co P4Ail';\, Oaft e �, 4� io3 7� IT 15 IJNLA\WLIL 1*0 MODIPY A DCX.IJM9NY OMARING TH2 5EAL. ANO %C4KW L= OP A L ICCNSCG CNGINCCR, t R 1-7'-0" I'ROr05ED AREA OE GHANGE - EX15T1N6 ( PATH TO PE RE MOVE D MA5fMP - DININCi l3E ROOM 5UNROOM ROOM d KITCHEN ? — x uttt Hill 11111 HALLWN(, BATH LIVING ROOM l3EI�ROOM Ci�'DROOM ` , r ENTRY DECK 1 ? 15 -rlNG r -cor, PLAN NOrE, DO NOf SGALr�OItAWtNG - WT2MtEN V1MEN510NS TAKE PM(:.eZ W.Z. IN CASE OP VtCGR�PM!CIEi 012 CONPL IC: i`i. NOTIPY tPV VrN PROPS llIONAL . Y •.1 �I OAF O O 74/ 4010 41- 73.8 r -, O Z L N� Z zp fl RL n z t- lu , t:7A-Pf<: 1.4JUN2CD11 51 IBt:T NO: 5-1.0 { \ IXI I }� Sherlita Amler, MD, MS, FAAP Commissioner of Health Director of Environmental Health June 1, 2010 Mr. Paul Hendrickson 19 Tyler Road Putnam Valley, NY 10579 Dear Mr. Hendrickson: Department of Health 1 Geneva Road, Brewster, NY 10509 Robert J. Bondi County Executive Re: Addition- A- 069 -10 No Increase in Number of Bedrooms 19 Tyler Road (T) Putnam Valley, T.M. # 73.8 -1 -5 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 from this Department dated June 1, 2010. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this Department. 2. The area of the existing sewage disposal system and its expansion area must be maintained. -J. tiYl`iuiliUiilllalUYG$ 1tTUSl JC'Li�JUQCGd Ni111 JVd1C1'S'd'Vill�'i1G`V1lG�� 1:C.�`iYCW`1UW 11uJ11 toilets, restrictors for shower heads and faucets etc. 4. The approval is for the proposed changes only. This approval does not validate any construction shown as existing that has not obtained proper approvals 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 (845) 278 -6130, ext. 43261. Sincerely, i4--e E) t Y-4 Gene D. Reed Senior Engineering Aide GDR:kly cc: BI, (T) Putnam Valley Environmental Health .(845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845), 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing / Home Care Agency (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 AM COUNTY DEPARTMENT -.OF HEALf APPROVED F OR 8EDR 0 D ._.COONT )ROOMS!l Wh EVISJON;AMA •I-IONS 301THBE E SuBm(rTEb TO THE PCDOH FOR AOP OVA t9i 'ov OL I ITI fr I � I I LLlolitylt 1 Uct'l /V /T____ j 4u 1 44. 73JR94 3A . ........... 11--j, _j I a ........ . . .... . ...... . .... .... . AM COUNTY DEPARTMENT -.OF HEALf APPROVED F OR 8EDR 0 D ._.COONT )ROOMS!l Wh EVISJON;AMA •I-IONS 301THBE E SuBm(rTEb TO THE PCDOH FOR AOP OVA t9i 'ov OL I ITI fr I � I t SHERLITA AMLER, MD, MS, FAAP Commissioner of Health . " Ll�lt11 ?i" ?1A'�1VIljL1'i�l K1; itN,1VlSIV Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT Director of Envi ADDITION APPLICATION RESIDENTIAL ONLY STREET 1Y;7V1,4r- a TOWN &d V` NAME (1. / PHONE MAILING ADDRESS w . 77 ,318 MAP # PCHD# /� DESCRIPTION OF ADDITION . rooA scL P NUMBER OF EXISTING BEDROOMS-3, : PROPOSED # OF BEDROOMS 3 (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: Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 - 6130. 1. Certified check or money order for $100.00. '2. Sketches of existing floor plan (drawn to scale, all living area including basgent:, Ci'll'be`U ' C'aUl T V-0fil blll`le'Cin :•' ` °' HA -1) 3. Two sets of proposed floor plans (drawn to scale —`With name, street and tax map #) * Non- professional sketches are acceptable and preferred. (See Section 3.d of Bulletin HA -1) 4. Copy of survey showing all well and septic locations, on the subject property to the best of your knowledge. Include date of installation known. Contact this office with any questions. 5. .Copy of Certificate of. Occupancy from the Town or Certification from the Building . Department with legal bedroom count of dwelling: OFFICE USE COMMENTS 5. Environmental. Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 2255186 Fax (845)225-.5418 Nursing Services (845).278-6558 Fax (845) 278 -6026 Nursing Home Care Fax (845) 278 -6085 WIC (845)278-6678- Early Intervention /Preschool (845) 228 -2847 Fax (845) 225 -1580 a SHERLITA AMLER, MD, MS, FAAP Commissioner. of Health ROBERT J. BONDI County Executive _�,. /�% . .•::;;: �.... �=,.. ,�:.,,.:'- .:- SE.�:.:�,:�i�t'1'. ;.:iao; .� _- < -. Associate Commissioner of Health J Director of Environmental'Health DEPARTMENT OF HEALTH l Geneva Road. Brewster, New York 10509 Town Legal Bedroom Count & Ptoposed Addition Status Re: NPnrjskson. (Owner's Name) Tax Map #_ 73.8-1-6 Address: 19 Tyler -Rd.. . Town: Putnam Valley -Year Built:. 1950 According to records maintained by the Town, the above noted dwelling, Is . xx. in compliance with Town Code. )ls.not in compliance with Town Code. The Legal Bedroom Count is: 3 This information has been obtained from: �� l:er'tiiicateYot'.Cccupa'ncy: COQ -65- 6503& 1995 -84 Other:. The plans for the proposed addition are considered: New Construction Addition to existing house only Teardown. and/or re -build allowed under Town Regulations ..Bu. Inspector. _...... pate ui1.. 6. Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 'Nursing home Care. Fax (845)278-6085 WIC (845) 278 -6678 Early Intervention/ Preschool (845) 228 -2847 Fax (845) 225. -1580 eluting t Well Permit $ , TOTAL �,�60 Rev. 1/85. BZS 4 ZBA Approval PCBOH - Approval Planning Board 94 :October 4 94 2w 19, TOWN OF\ PUTNAM VALLEY Zone District PERMIT RECORD bldg. Application is herebV made for Permit Work to start Description Sun Room.& Deck Tyler Road TM#73.8-1-6 Location of Premises-Street or. Road _5! SEC.- BLOCK- LOT FRONTAGE Depth Rear ACRES (other descriptjoh) or number of square feet SUBDIVISION NAME TEL.L_S28-8149 Paul & Susan,Hendrickson 19 Tyler Rd.-Putnam Valley, N.Y. OWNER ADDRESS IUSE CONST. ROOFING Dimension of Building I I Family Wood Wood Shingle Paved 12 Family Steel A Shingle,.,._..__ Dirt Width ____QaDAh.. StArins eluting t Well Permit $ , TOTAL �,�60 Rev. 1/85. BZS 4 ZBA Approval PCBOH - Approval Planning Board _5! eluting t Well Permit $ , TOTAL �,�60 Rev. 1/85. BZS 4 ZBA Approval PCBOH - Approval Planning Board TOWN OF PUTNAM VALLEY Application N? 7 7 Zone District ........ 4&$1*11*1111111 APPLICATION FOR BUILDING PERMIT Application is hereby made to erect (alter) .................. ------------ - ------- - ---- - -Work to start.... JA ........... Location of Premises—Street or Road. b?"G411jocil�& .... oil! ....... . SEC ....................... BLOCK..._...---- ........... LOT...- .................. FRONTAGE.. ..S.9.1 ... *.. Depth-2.Wilft Rearzl� ...... ACRES (other description) or number of square feet ......... .............................................................. ....................... .... ................... ------------ .. .. ..... . ..............................• ....... ......... . ...... ADDRESS —6441.w. ...... ..... . ......•...•........ . OWNER ............. . 2 Vk&zq �41 Dimension of Building Width Depth Stories-..,, x x 39b x x x x x Type FoundatM.....A.I.C4 Size & Use Each ...................................... Room with Window Area.... Lrz ----- ......................... . . .;1;W.*4t1...................... ................. BLOCK ..................... LOT ---------------------- CRES (other description) or number of square feet .......... .. ..................................... . .... .................................................. I ........ ... . .......................................... iWNER 24 --------- ............... ADDRESS ........ 7/... USE CONST. ROOFING LAND Dimension of Building I Family 6oO Wood Wood Shingle sued Width Depth Stories 2 Fandly Steel Asb. Shingle Dirt Log Cabin Brick Tile Oiled IBungalow Concrete bfetal waln Apartment -1- Stone ook 1 Store FNDTNS. I INTERIOR ®r time Store &. Apt. Stone Room STATE SUPERINTENDENT aws Store & Office Concrete AOL Rooms w. Pools Office Blocks Apt. en. courts Gas Station Brick the Open the Fftlshed I jOTHER BLDGS. 7M -.iE �41 Dimension of Building Width Depth Stories-..,, x x 39b x x x x x Type FoundatM.....A.I.C4 Size & Use Each ...................................... Room with Window Area.... Lrz ----- ......................... . . .;1;W.*4t1...................... ................. BLOCK ..................... LOT ---------------------- CRES (other description) or number of square feet .......... .. ..................................... . .... .................................................. I ........ ... . .......................................... iWNER 24 --------- ............... ADDRESS ........ 7/... USE CONST. EOOFWC ROOFING LAND LAND Dimension of Building I Family Wood Wood Shingle Wood Shingle Paved Width Depth Stories 2 FamIlY Steel b _ Shingle Asb. Shingle Dirt Log Cabin Brick Tile Tae Mrde oiled Bungalow concrete Metal swamp Apartment -1- Stolle ;.;zl -11.0 Brook ®r time STATE SUPERINTENDENT rKfr I }s EXISTING; 15T FLOOR PLAN SCALE: 1/0' = I ' } f PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES __. _..._..._. _ _... _........__... _ P T _ SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT DATE o PROPOSED INSTALLER -rVjf, ADDRESS hip (i.e. oy6ner, tenant, contractor) FACILITY TYPE PCHD COMPLAINT # PHONE # EGISTRATION /LICENSE # IdW / o 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 of the repair. I, as owner,agree to the conditions stated on this form !;Z5 4,,,�k f of SIGNATURE TITLE DATE (owner) .. _... _ j; .iha,_ ant r CtaliF! GF_. t.'i �f .r ri %i wit tharni_ fi(fl�.(1 ?.ihiC ►1CI17?it t(� ,tilA CGf4ir_. �� /St[+ n rNr.�i� _ � -. - .. .. SIGNATURE TITLE. DATE (installer) Proposal apl2roved with the followi onditions: s 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. 1191 CRNIM. U.IC UML.T Proposal Approved Proposal Denied ❑ _ = s 17110 /v / o Inspector's Signature & Title Dat6 4 Exp' atio Date ,Repair proposal is in compliance with applicable codes Yes 0 No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 \, SHIERLITA AMLER, MID, NIS, FAAP Commissioner of Health Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTTI�I� All information below >titaust be f, oily completed prior to any scheduling. ROBERT J. BONDI County Executive ROBERT MORRIS, PE Direct& Of I?,sjironm! ntai nrail;f DATE: ENGINEER OR Pte: � ( s x G PHONE 02 - O 9 PERSON TO CONTACT: _ ❑ NEW CONSTRUCTION o REPAIR PROGRAM o ADDMON PROGRAM REASON: DEEPS: Be PERCS: L' Pn'.P TEST: ❑ ROAD/STREET. 17 -7 -e /i. r N ead TOWN: t 4�p- alm 41lew TAX MAP #: SUBDIWSION: ]LOT #: NYCDEP CRITERIA FOR JOINT REVIEW AND 'MESSING OF SOIL, TESTING YES NO ❑ ❑ Proposed SSTS within the drainage basin of Nest Branch or ]Boyds Corner & Crotn n Falls Reservo;rs, ❑ ° ° ❑' P riroposed SSTS with 5U(6 feet off a reservoir, reservoir sten2 or control lake. ❑ ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. 13 ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES 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. The Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered ves to any of the questions, i1TYCDEP must witness the soU tests. This Department will coordinate :n mutually sidtable time for field testing with the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP 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. OR COUNTY USE ONLY DATE: 5 TIME: /67f COM 4ENTS: PZQ. FOR FIELD MTjNCar.LV Environmental Health (845) 278 -6130 rax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278-4026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early intervention/Prescbool (845) 278 -6014 Fax(845)278-6648 6'd 6969-6LZ (9t'8) IIePuAi d99 :Z0 O6 LZ AV May 12 10 04:33p Susana 8455288149 P • 1 PUTNAM COUNTY HEALTH DEPARTWNT DIVISION OF EN'V'IRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES NO Internal Use Only PERMIT i# J;vair Pemt issued in fast s years ❑ Not 'n watershed L7 U Repair within 9o}d's Comm. W. Eranch or Croton Falls Res. 0 Delegated ❑ C Repair oa&m 2t9 it. of a watercourse or 7EC.maWed wolamd ❑ Joint Review SI"E LOCATION. t q OWNER'S NAME MAILING, ADDRESS APPLICANT li TOWN 81b 1% fj&V ''M # PHONE# I mane 8 R614a;ict ship (f.e-. oKrer, tenant, c_oniram) DATE FACILITY TYtiE � t }�� _ PCHD COMPLAINT q P'RQPOSEtT INSTALLER IQ t,, _ PHOi11E #,��r'��aJ ADDRESS rY- EGISTRAT10N LICENSE # 44 y _T P o psai (include a separate sketch tocating 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 proxssal from licensed prctessiona° depending on the nature aid extent of the repair. I. as owner.agree to th Conditions sl4ed Q s loin' SIGNATURE .TITLE a. ..� »- °i; °iirE se5ti :iris`tallei, a/gr�e,e�too comply wit `ti.e conditions of this pemrn for the septic system reps SIGNATURE TITLE DATE �� /0 (installer) Proposal- anomved with a %i en 'UOnS: I. Procurement of any Town Permit, if aoplicable. 2. Submission of a3 bugt repair sketch by the septic system instal;e: within 30 days o.- the repair, in duplicate showing: a. Owners name, Site Street Name. Town and Tax krap number _ - - b. Location of installed components tied to two '.5ted points c. System description (e.g., 1250 gal. Corcce:e septic tank, etc.) d. Installers name and phone number 3. Systc-rs") repair to be pertow ed in accordance with the a�iove proposal and conditions 4. The proposed SST repair is considered a bein fit de_igr and there is no gtwrantee to the duration at which the completed SSTS repair will functioa_ 5. No completed work :s to ae bacidilied until au ttorization W do so has bee i obtained from the Oepalment. W ERNYAL USE ONLY Approved. ❑ Proposal Denied ❑ nspxtor's S gnaatre & Title is in comnllance with COPIES: PCHD; Owner, Inatailer PC -RP 99ML Z.-d 6353-6LZ (9W codes Date Exoiration Date No ❑ Rev. 2/p7 IiePU4i dLG:tri3 a ZL Kair0 .2 fol L 4 a m� A gi T rd egg L-2-.1.L. qII C'D�' •� 1 j LL IA 0 51d o-7 Wl� #A W cic d NQ O rl ft U' a Shect of PUTNAM COUNTY DEPARTMENT OF HEALTH . -... - T�TY'1,9 10e 1 T ZIN II - ..>�_ � � _ ,� �...:�..*m =:.. ?.ems �- ::.F��.ei..:�i_���' •_ ,. � i�� FIELD ACTIVITY REPORT Street Town 1 State Zip PERSON IN CHARGE Name and Title TYPE OF FACILITY : S r K j ��P— FINDINGS: well pet ocvteil-P® Signature and Title RFPnRT RF.CFTVFT) BY: I acknowledge receipt of this report: SIGNATURE; 02/96 R 0.17 . Title; t J, PUTN,-.A--VI COUNTY DEPARTMENT OF HEALTH DIVISION OF ENIVIRQNNMENT�kL HEALTH SERVICES DESIGN DATA SHEET -'SUBSURFACE SEWAGETREAT1\4ENIT SYSTEM Owner: Address: L2 7-yl,6;2 R-7,) Located at (street): TM 9 Section: Block —Lot Municipality: Watershed:• e3 SOIL PERCOLATION TEST DATA Date of Pre-soaking: b Witnessed by: Date of Percolation Test:- Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) I Start - Sto*P Water level drop in inches Percolation Rate min/inch 2 .3 ..4 .5 '2 3 4 5 2 3 4 5 2 4 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolacion test hole. (i.,-, < [ min for 1-30 min/inch. < 2 min For 3 1-60 rnln/inchi. 4su.: sr aGv�s :LristrlY'm.� "-`r�r7srY... -NU ,.- �.'„�'.. ci" <yr`.i�:c: =... -� Y-:c+e �.. "-: `.` ": �.-° e$- '.::.3�- :;tyY :'= FCJy�•µ�se:•i <r �.ri ii^- _ _ :W=74 :- -., _ MTEST 'PlTrbaTa :.,. �,.Y:�,= . ,: �... :::�,:.�.:�;.,. -, �,a:::.�::�:,r�,:�..;•�, °:. DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES CE l Fi HOLE +°+ HOLE # HOLE # HOLE # HOLE # G.L. - .� �• T 5� 0.5' S� 1.0' A y 2.0' 2.� a 3.0' 3.5' v 6 vej 4.0' o ` 4.5' 5.0' 6—,V 0 5.5 1 'e 6.0' c 6.5' u 7.0' amvlai TO ' 8.:.' Indicate level at which y� ourdwater is encountered 5 i 4 � / �✓ Indicate level at which mottling is observed Indicate level to which water level rises afer being encountered Deep bete observations made bv:Gr Date DesiJn Professional Name: Address: S i anavure : Tlacirrn Prnfaccinn•il = CPni 4 SHEIILITA AMLER, MD, MS, FAAP Commissioner of Health 1N-AE , RN. MSN_ _ Associate Commissioner 6f y'eaftlr DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTING ROBERT J. BONDI County &ecutive ROBERT MORRIS, PE All information below must be fully completed prior to any scheduling. DATE: ENGINEER OR FIRM: S PHONE #: FJ/S'- 2 PERSON TO CONTACT: lal ❑ NEW CONSTRUCTION ❑ RE PA& PROGRAM ❑ ADDITION PROGRAM REASON: . DEEPS: Er PERCS: ET" PUMP TEST: ❑ ROAD /STREET: TOWN: P..44�P-41-M SUBDIVISION: -OVV7 R: Ile TAX MAP #: 73, 8 / — 6 LOT #: NYCDEP CRITERIA FOR JOINT REVIEW AND NVITNESSING OF SOIL TESTING YES NO o i( Proposed SSTS within the drainage basin of Nest Branch or Boyds Corner & Croton Falls Reservoirs. ... _ . n - .... j L "Iy S �i� "i(?►�J �.Z'i .`�c�1. S '.° �.i` ar rPCti /1�C c ,UAt stiCilY Ci]( - o tZ ii�..�&10E�;� ❑ o Proposed SSTS within 200 feet of a watercourse or a DEC wetland. r1 Proposed SSTS design flow greater than 1000 gallons/day or SPDES 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. The Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered ves 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 Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP 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: MIE- COMMENTS: 1 C163 ROQ- FOR RUD TMN[2K.Y Environmeotal Health (845) 278-6130. Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225.5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 Z'd 6969-6LZ (5t8) 112puAi dbZ :CO 06 Z6 ady 11 iconi Camping 4dult ation j Ch-ristian CornOrs 20 'IV TomPkin Cornenq Rest otn;r Are GN OAk A L B let 'Zi 01 4 Sunnybro uftAs ft Sam Lake pCorng$ ;Ponds/ 'T Oscawa J6� �an 'A 10579i i C7- E3 C uyic�' N I Ciro Corner 24 7, 22 Bar rg FM Pond W —Lr 0 PIO I pt A UTNAM Vg -LEY J 4 me Syr EQXQ�� Adams Corners 7., Aose Hill Park Town Park,! Cem A -1 ua I 20 AY 10 21 utnam COUNTY alle VALLEY TNA Ou ;y cr MS E CHESTER C ...... f eff e 6N S-r� IAER'� EXT 0 W, N kla %SSESSMENT PURPOSES ONLY 0 BE USED FOR CONVEYANCES �� REVISIONS SPECIAL DISTRICT INFORMATION �`� RfMAM VAL CWTIAL SH DI ICr -•• 2SOS STATE LINE COL y LINE TOWN LINE : eu•y� • we s•oom +n/p aw fiAE •f- .. -... RO M VALW FIRE PRDIECTION DISTRICT :S W. SEWALL COMPANY ER STREET. OLD TOWN, MAINE VILLAGE LIK GLM LIMIT PRGPERTY LINE mIaixu iet i iue �� A 0 1 Z-T- 11/2011 da 42' 2. 42' 3. Chambersz Junction boxes ADS Bio Diffusers Hendrickson 19 Tyler Rd driveway. ION- MEMORY TRANSMISSION REPORT - ..'g. - n.. - .,�.• _ .. c+.� -•+`• r. � .,,.,.. r:�.i ter+, +«i:>Y =•eA- *1* .- IEL'NUMBER : 845278792 1- ' NAME ENVIRONMENTAL HEALTH FILE NUMBER 281 DATE NOV -22 12:14PM TO 85268806 DOCUMENT PAGES 002 START TIME NOV -22 12:14PM END TIME NOV -22 12:15PM SENT PAGES 002 STATUS OK FILE NUMBER : 281 * ** SUCCESSFUL TX NOT ICE * ** SHERL[Tw AM L[y R, Ma. MS. FAAP COrntn /ssionar of Health LORETTA MOLINAR7. RN. MSN Assac /ore Cornrnlss /over of Health Date• QEPARTMENT OF HEALTH 1 e3oncva Road, Brewster, New York 10509 F'AX COVER SHEET ROBERT ,l. BONG[ county ,F— - ..rt,.e ROBERT MORRIS. PE O /ratter ojs"Weenmcnrol Haalth 7c�c`�% No. Rages: 2- (1ncluding cover sheet) Vrom- Gene D. 12ccd Putnam County Depairtment of Health ./ Fcar your inYormatlon P1Case respond For your review Attached as requested As discussed Please call Notes /Messages .��rr ��a �o�+�4���4°• r+ C „/2 SZZi , xn the event or transmission/receptioa difficulties please contact this office at (843) 278..15130, ext. 2261 Hnvtronmontni Healtta (845) 278 -6130 Fax (8aS) 278 -7921 Water Supply Seotioa (845) 223 -5186 Fax (845) 225 -5418 Nursing setvl.es (845) 278 -6558 Fax (845) 278 -6026 %V C (845) 278 -6678 Nursing Home Cara Fax (845) 278 -6085 Early entarventton /Presa600l(845) 278 -6014 Fax(845)278 -6648 r, -Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH 11 YJ E IN y-1 IR FIELD ACTIVITY REPORT NAMF.• Tel: Street Town PERSON IN CHARGE -, Name and Title TYPE OF FACILITY: State Zip a FINDINGS: &20 �Uff'U I Signature and Title RFPO'RT RF.CRTVF-T) BY.0 I acknowledge receipt of this report: SIGNATURE; 02/96 R P-17. IROY PIPE FOUND ` a a t? k�.�� :1'F. dpi __ "'ds �.. _ .. _.- _ _ ..�•a ... 's•�a�.c•crx _ — •�._:.. -, i �_... ��= �. e. z -x. '•.i:; �'T: `g � .. U,xe N J•� N /F`HESSION` n ;h IROR PIPE COOYO i y r.. 'rt t POLE % . •�WELLTeD A c TOTAL L AREA j ACRES SQ.FT. .. , ..._ _ ..., ...� ••-_ � _ .m .--1.028 � �. �.....,. _' � .. •. ... .7 .� .� ., :_:;.- 1�.:�'�... ee':m •.: o :o -:... e P AL OR 7HI& SURVEY MAP NOT BEARING THE' LAND SURVEVO ^•'S RUE COPY EMBOSSED SEAL SHALL NOT BE CONS TD BE c OR ON FOR FICATI0N5 T ERSON HE P WDICATEO HEREON SHALL RUN T WHOM THE,SUgyEY IS.PgEPAREO, AND �HALP :TO :THE ..TITLE COMPANY, OOVERp1MENTAI AGENCY NNG RiSTIT(1T10N ,LISTEp,;•HEREON, AND TO THE ASSIGN fNE LENDING IN$71TUTIOH,...OUARANTEES OR E IuoT., TRANSFERg81,p Tp' CEATIFICq_ 17 OWNERS:.' BiSTITtJTpNg OR ZED'' ALTERA116N OR ADOITRON 'TO 'THIS SURVEY MAP IS :ATMIN OF., LAW. ..7308' . PARAGRAPH 2: OF THE NEW YORK LAW: • :..:.. AP IS- :CERTIFIED ONLY TD SUSANA R: HENDRICKSON BA ek t LAND SURVEY MAP PREPARED FOR- ' PAUL W It SUSANA R. HENDRICKSON SITUATE IN THE TOWN OF PUTNAM VALLEY . Pqc 01' NEW PUTNAM .COUNTY 'r`� Hoc' OC NEW YO gK Aft SO '' f♦f �l %� i'Sl�+N+jS 4r LOT 13 N/ F BARGER n ;h IROR PIPE COOYO i y r.. 'rt t POLE % . •�WELLTeD A c TOTAL L AREA j ACRES SQ.FT. .. , ..._ _ ..., ...� ••-_ � _ .m .--1.028 � �. �.....,. _' � .. •. ... .7 .� .� ., :_:;.- 1�.:�'�... ee':m •.: o :o -:... e P AL OR 7HI& SURVEY MAP NOT BEARING THE' LAND SURVEVO ^•'S RUE COPY EMBOSSED SEAL SHALL NOT BE CONS TD BE c OR ON FOR FICATI0N5 T ERSON HE P WDICATEO HEREON SHALL RUN T WHOM THE,SUgyEY IS.PgEPAREO, AND �HALP :TO :THE ..TITLE COMPANY, OOVERp1MENTAI AGENCY NNG RiSTIT(1T10N ,LISTEp,;•HEREON, AND TO THE ASSIGN fNE LENDING IN$71TUTIOH,...OUARANTEES OR E IuoT., TRANSFERg81,p Tp' CEATIFICq_ 17 OWNERS:.' BiSTITtJTpNg OR ZED'' ALTERA116N OR ADOITRON 'TO 'THIS SURVEY MAP IS :ATMIN OF., LAW. ..7308' . PARAGRAPH 2: OF THE NEW YORK LAW: • :..:.. AP IS- :CERTIFIED ONLY TD SUSANA R: HENDRICKSON BA ek t LAND SURVEY MAP PREPARED FOR- ' PAUL W It SUSANA R. HENDRICKSON SITUATE IN THE TOWN OF PUTNAM VALLEY . Pqc 01' NEW PUTNAM .COUNTY 'r`� Hoc' OC NEW YO gK Aft