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HomeMy WebLinkAbout3513DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74. -1 -5636 BOX 28 Iffm ., ,11 r ` r . 10. .,. 1' ir 03513 ALLEN BEALS, M.D., J.D. Commissioner of Health r. �'' %'�>E`RT' �VIURRIS, P.E., MPH y Director of Environmental Health November 19, 2014 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 - 1390 Fax # (845) 278 -7921 Karen Harel 215 West 91't Street Apt. 125 New York, NY 10024 Re: Addition — A- 151 -14 No Increase in Number of Bedrooms 71 Rochdale Road. (T) Putnam Valley, T.M. 74. -1 -5 Dear Ms. Harel: MARYELLEN ODELL County Executive This Department has 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 November 19, 2014. The addition is approved with the following conditions: 1.. The total number of bedrooms must remain at two without prior approval by this .;...........:.- :....w.:... -... �._._ 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 de_ vices, i.e., new low flush toilets, restrictors for'shower heads and faucets, etc ... 4. The approval is for the modifications only and does not validate any construction shown as existing that has not obtained proper approvals from other agencies having ' jurisdiction. 5. This approval is valid for two (2) years and expires on November 19, 2016. Any permits or variances required under the jurisdiction of the Town of Putnam Valley are the responsibility of the applicant. If you have any questions, please contact me at (845) 808 -1390 ext. 43261. Respectfully, Gene D. Reed Principal Engineering Aide GDR:cml cc: BI (T) Putnam Valley 1:. is R. / P=kl tag,-/ ALLEN DEALS, M.D., J. D. MARYELLEN ODELL $00 Commissioner of Health - Cownly Executive v9^'. ��i1 "<'A`�1C:sF�- .CAf+[+la..+^Pfa:. ••Y a�f... b` ,.b T. �rvq� -•+Y 4lv: - ^ -v v4! ^i�.Ma'A•- L'�f•l, rLITCTBV�'e'iPwC Cr. tr.- h`r -. y.� .�:o�iT.'�:.. :�!r. �+ =ry -�• ROBERT (MORRIS, P.E. NTH Director ofEnvironmental Health 1 Geneva Road, Brewster, New Fork 10509 Phone .# (845) 808 -1390 AIDDITION APPLICATION - RESIDENTIAL ONLY Atro..;>fi Cad ��,s7'ItIS �oe-, - r Owner's Name: 1� � l %�L- Owner's Phone #: ��' °1� 4�> Site Address: ! � �� D�� 'own: RV � Tai leap # Owner's Mailing Address: �1 `�1 S% 57' ( ZS Illy A1�! Owner's Signature: (Description of Proposed Addition: 1ei d1 tit. j` Hmf,R *Number of existing bedrooms: Total number of bedrooms (existing + proposed):_ *. ((FRONT CERT. OF OCCUPANCY OR CERTIFICATION FROM MOLDING INSPECTOR) * *Any addition which is considered a bedroom requires formal approval of plans (Construction permit) epar€d -b.a ProfessianalEdIncr'or Registered - Architect m accordance -with a pp licable.�sectis ofthe - - Putnam County Sanitary Code.- Please submit this form and the following to Putnam County Department of Health, 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 808 -1390. 1. Certified check or money order for $100.00. 2. Two sets of sketches of existing floor plan (drawn to scale, all Paving area including basement, to be shown and dimensioned and use of each room specified). (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. 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 Rev. July 2013 5. w ALLEN BEALS, M.D., J.D. Commissioner of Health 'l• / L �y`O'.'Y AJ'1 i�!,M Vi'Y��.�;..11"•LJ.' Director of Environmental Health a MARYELLEN ODELL County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Town Legal Bedroom Count& Proposed Addition Status Re: Xf€ , (Owner's Name) Tax Map # Address: Town: 2�nri Vd� Year Built: 'g150 According to records maintained by the Town, the above noted dwelling, is W In compliance with Town Code. Is not in compliance with Town Code. The Legal Bedroom Count is: This information has been obtained from: Certificate of Occupancy: Other: The plans for the proposed addition are considered: / Addition to existing house only e/ Teardown and/or re -build allowed under Tow" n Regulations 04dl,ra 14 OLA Building Inspector Date 5. ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health . November 3, 2014 Karen Harel 215 West 91" Street New York, NY 10024 Dear Ms. Harel: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 =1390 Fax # (845) 278 -7921 MARVEL .,EN O D1ElLL County Executive Re: Addition- A- 151 -14 71 Rochdale Road (T) Putnam Valley, T.M. 74.4-5 I have received and reviewed the plans for the proposed addition to the above mentioned residence. Based on the information submitted, the above mentioned addition cannot be approved for the following reasons. 1. The proposed loft is considered a potential bedroom. 2. The legal bedroom count for the dwelling is two -. The potential bedroom count of your proposed addition is three. 3. The addition of a potential bedroom requires this Department's approval of a revised. septic ....system - l frsr a r ,f�ssio. dagi r` do .. ��r__ ._��.:.. r....... Please revise the proposed floor plan to reflect no more than two potential bedrooms, or have a professional engineer or registered architect design a sub-surface. sewage treatment system meeting present code requirements. If you have any questions, please contact me at (845) 808 -1390, ext. 43261. Sincerely, Nzloeek Gene D. Reed Principal Environmental Engineering Aide GDR:cml P.O. BOX 232 FISHIQLL, NEW YORK 12524 (��TC T �T ('t D n D j(��T (845) 897.9400 PHONE 0111 SMWTd.Q��1;XO$� Ol�t'1Tl�JI�"'-` r (845) 897.9490 FAX , • www:l`Ty[rzioNSi�ivcTiar Kay Harel 71 Rochdale Rd ev k a 10 ACo , ^ L 2 iGv� Putnam Valley NY 10579 October 1, 2014 RE: LETTER OF AUTHORIZATION To whom it may concern; This letter is to serve as my authorization allowing Nurzia Construction Corporation to submit an a application for a Demolition permit, Building Permit or an addition permit (BONA) on my behalf. If you have any questions or need further information, please do not hesitate to contact either myself or a Pete Nurzia of Nurzia Construction Corporation (845) 897 -9400. j Sincerely, Kay Harel CUSTOM HOMES - LAND DEVELOPMENT - CONSTRUCTION AND REAL ESTATE MANAGEMENT COMMERCIAL CONSTRUCTION - REMODELING - INSURANCE RESTORATION m Three .: .. ». _'rs�;':��y�y,;'.�d. -. �wp d.tF..�b -Fbw-s r �2.. .r, .% si;,`. � .. .. F- •t�.:�++ +�:�-y�`si�i ' If you have.any questions or. concerns, please contact t#�. Three Avows Planning & Building Committee Chair. as %llovsis: .- �..ry�... •�ws�w +l. ay.• ..: .�.. � i c s. �. .....,.. ..�...r. wu e. � •.yr +. —� Ty PUTNAM COW OFFICE OF EA1ERGEMQY MMAGEMENT Thomas C: Lannon, sr.,Director Emergency Management /.IT April 15, 2013 Kay Harel 71 Rochdale Rd Putnam Vall6yj NY 10579 Dear Resident -MaryEllen Odell County ExecuVW6 In a recent review of 911 addressing for your community, it became.. apparent that there was an issue with the current addressing. Numerous. houses are on side streets off. of Ro.chdale Rd, yet still use a Rochdale Rd., address. ' From a mail delivery point of View this was not an issue, however, from an emergency re'spo:nse point of view, this is not in conformanc6 vififth the county policies.. Basied on that information, we are re-numbering the units within this community utilizing now. house numbers.' While we reafirielhat it is. not easy to have-a new ad -it is importantfor your safety: Rif yourin -addrds—h 'thoattachbd dress, ew s, please see Please be sure to post. your address.number.,6t the entrance to your driveway and on your building. Posting y.o6r house number can'greatly assist the police,,fire and ambulance services in locating you In the event of an emergency: We Will. notify the Putnam Valley Post Office of these address chdnges�. We Will also notify Verizoni for the residents that we have landline phones for. I Would like to'thank Esther Brill for her assistance. If you have any quettlions with your aiddress,.please'feel free to contact Carol at (845) .808-4005. v ry truly yours,. Carbl Cavaflaro- Putnam 911 Coordinator • - _ _ : <aii isx;l.' S\ �il.. r'' �`zS'.K','�",C'i:4fi�w���.l,..' .�'�,°,a�. 'Ebert Ln Wisotsky, Eric & Megan 20 vvy rv, 3,. x - t Ruben, Julie �z w. x•. 8 Abrams, Brad/IUarup, Irene 28. 11 Brown, Helen .26 12 Piano Mountain Rd -, _ s - �BiKO. i�f.. • - -.: 4: •.- �.YiY��iij:r:»`i>: x.. i'_:r _'ZCa�?�:ii9c+ t .. ..v.. w �'1 ye"::i!tr`�:. �.% =:_w ,t •f" �^~ �V.��w!'Y �, OP Y�:C.). �'. •'S'•A Tulip Tree Ln Dmoker, Nina & Hal 51 10 . Zolot, Bruce & Joan 53 16 Broksky, I(Oren. & Gabe 55 20 Gallagher,,- OkelMarsten, Ro)ie . 57 30 Hall-, afcy & Ron -/ Levine, Roberta . 59 27 • Cordes;: ldgar/Humphrey, Sylvia 61 23 ii�ig��rrl�[ike Rochdale Rd 'Ebert Ln Wisotsky, Eric & Megan 20 2 Ruben, Julie 2-2 8 Abrams, Brad/IUarup, Irene 28. 11 Brown, Helen .26 12 Piano Mountain Rd Schaffer Ln White, Eleanor Eleanor & Hilary 30 • 9 White, Bruce &Lisa 32 11 Pita, Dorothy 34 15 Bogin, Merle/Berger, Wally 36' 17 Sklar, Rick 38 1'9 Tulip Tree Ln Dmoker, Nina & Hal 51 10 . Zolot, Bruce & Joan 53 16 Broksky, I(Oren. & Gabe 55 20 Gallagher,,- OkelMarsten, Ro)ie . 57 30 Hall-, afcy & Ron -/ Levine, Roberta . 59 27 • Cordes;: ldgar/Humphrey, Sylvia 61 23 ii�ig��rrl�[ike Acorn I_n ier /StdOh& is, Mitchell ° 73 ` t ` _ 7 .16 ►1 Freund, Vivian 75 26 ie! Ctidstina : -.. 7T , _ r .. .... y . _27 n/Shaffer 79 17 Piano Mountain Rd Warsten; RoAe 109- 9 107- 10 /Aislirig 105 2 - .. Primrose Path argss, David 118 4 • iV silaIds, Stelio 120 8 arr 122 12 124' 14 �J• q,. �sR+: e'- Fsr- ...x:. }���..r•.2LL•:'��.;.'r.�z .. -l:�in :.r= aa.:.... ri�r�••.� ✓.r :•.�' -.ar: r.,.: •: p' -� :v ,o.- ..:.;...lwca v S—add MARC L. SAIDEL SHERYL M. SAIDEL' (� ERIC M. SAIDEL ATTORNEYS AT LAW 'Also admitted In Connecticut PO. BOX 308 PARKSIDE CORNER ROUTE 202 YORKTOWN HEIGHTS, NY 10598 ERIC H. HOLTZMAN TEL. (914) 736 -6500 FAX(914)736-6581 www.saldelesgs.COM of counsel VJA UPS Karen L. Harel 215 West 91st Street Apt. 125 New York, NY 10024 RE: Site #40 Three Arrows August 9, 2013 Dear Kay, Enclosed please find the following: 1. Acceptance of Assignment and Assumption of Proprietary Lease 2. Stock Power 'J I. -Ass riine]it Rrop:aet j+:Leasa: .p..r.ya -�.• �y 4, New Stock Certificate Please keep these documents in a safe place. you have any questions. please call or e -mail. Very truly yours, SAIDBL AND-SAIDEL. P, / SHERYL M. SAIDEL SMS:pe ^. C. .SIGNME.•A�Ni.�•':,�.4a a; hi R_r.a�•��s M:r"�a- =' „.�. w. %rirv� .��7 -L:u a...� .�.:e..i,�i� -. ','�,.o..i ACCEPTANCE OF AAT AND. ASSUMPTION OF PROPRIETARY LEASE KNOW THAT KAREN L. HAREL, the undersigned Assignee named in a certain in- strument of assignment dated . 6 1 -+1 2013, executed by KAREN L. HAREL and YAIR H. HAREL, as JTWROS, Assignor therein, in order to induce THREE ARROWS COOPERATIVE SOCIETY; INC.,. Lessor therein and owner of the property at Barger Street, Putnam Valley, New York to consent to the aforementioned assignment of interest in the proprietary lease and to transfer the shares of the Lessor to which said proprietary lease is appurtenant, and in consideration of such assignment and the consent of the Lessor thereto, the undersigned HEREBY ASSUMES AND AGREES TO PERFORM AND COMPLY with all the terms, covenants and conditions of the proprietary lease to be performed or complied with by Lessee, as If the undersigned. had originally executed the proprietary lease as Lessee, and further agrees that of the request of the Lessor, the undersigned will surrender the assigned proprietary lease to the Lessor and enter into a new proprietary lease for the remainder of the term thereof, in the same form and on the same terms, covenants and conditions as the assigned proprietary lease. IN WITNESS WHEREOF, the Assignees have duly executed this acceptance and assumption instrument on • uf-te Lw,>�' 7 , 2013 L. HAREL State of New York } County of �,`jr -0e% } ss.: On 8 1-4 1 f 3 before me, the undersigned, personally appeared 6A r..er1 L... I-t,�,;,J personally known to me or proved to me on the basis of satisfactory evi- dence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he /she /they executed the same in his/her /their capacity(ies), and that by his /her /their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individuals) acted, executed the instrument. (signature and office of individual taking acknowledgment) MELISSA LEE RIVERA Notary Public - State of New Yark NO. 01 RI6263073 Qualified In Bronx Cou ty�� My Comm;ssion Expires P � ..:..�•� ?.• ..,�, ,�•.�._ .. :;� r . ,�:.- < � ...:...,� �:�� -, ..�.;:� x: �� ,t,���'Iiree4Ai•i °ows' Putnam V lley, NY SUMMARY OF PROPERTY Address: 71 Rochdale Putnam Valley, NY Description: Size /sqft 1,154 Rooms 5 tr , Bathrooms 1.5 Loft sgft 0 Loft Utility n/a Basement sgft 0 Basement Finish Unfinished Basement Utility Average Heat Electric AC Central Insulation Partial Water Well ..; ...... -. _ _ .: ....n..... _..�............ �C .+rs .. «. .. .. ... - .... .a . .n..r.. � �F- -�•rt. ca..« .. .. ... .. r Deck sgft � .. ...a a .. 358 Patio Size None Covered Porch sgft 0 Fireplace /Stove Fireplace Shed Small Miscellaneous None House Appeal Average House Condition Average Site Appeal Above Avg Site View Average Indicated Value: $140,118 75 ? 2 OG.) y Q: ..Fl(ll in I a W, M. RATIVE ,MW� =mm--T4w-4-224 no I A. t7-2�7 KAREN L. HA#tEL MIA TY INC. 1 m October 1, 2014 Putnam County Department of Health 1 Geneva Road Brewster, NY 10509 ATT: Gene Reed RE: Application for addition Dear Gene, P.O. Box 232 RSHmLL, NEw YORK 12524 (845) 897 -9400 PHONE www.NuRziACoNsTRucnoN.coM VIA HAND DELIVERY Please find attached application for addition. We are proposing a complete knock down / new build. The future house will be the same footprint, location and current bedroom count as existing. Please review and give me a call with any questions. I can be reached at 845. 897.9400 or (914) 490 -6492. Our company is acting as agent on behalf of the owner. We have attached a letter of authorization F'rf/'P1°!`��F,62fFYP'r_ .. ,»... «_ ..,.....--- •rv_.a....._.a,..... --.- �—....-.:_..... ..-.. �.....::..._..- .- �— ..�— ......�......._._..... ,- ....r......... - ....�:v- :....._:::�..,:.'_. Sincerely, President, Nurzia Construction Corporation CUSTOM HOMES - LAND DEVELOPMENT - CONSTRUCTION AND REAL ESTATE MANAGEMENT COMMERCIAL CONSTRUCTION - REMODELING - INSURANCE RESTORATION Date /19�J'° .... TOWN ` TNAM VALLEY Application No. APPLICATION FOR BIIII.DINC PERMIT. Zone District ` i Application is hereby made to erect (alter) :. ��w°.,....Work to start x _/ •., v. ................ . ...... Location•of Premises — Street or Road ..... ...... ..... ............... . SEC............ BLOCK ........... LOT ........... FRONTAGE Depth. % vRear.... . . ACRES (other description) or number of square feet .......... ................. /�,. /r, . ADDRESS .:` .. q m ' ''2`e . _1 Dimension of Building Width D,eith Stories X. X X X x Type foundation, Room with window area ..... . Sewerage type Size of septic tank .. ,..: Lineal Ft. Drainage .............. Size of dry wells ................. Additional information: .......... . T'. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . this appl�icqtion must be accompanied by copy of surveyors map and complete plans, specification, and all information equired y. oning Or i a an Sanitary Code when requested by inspector. I, ........ the applicant do hereby a that th b Wst ements are rue to my knowledge and elief. Fee ° ' Signature of Applicant .... .... .... 1a,. . EX USE ( CO STRUCTION I ROOFING I LAND FAMILY IGOD WOOD SHINGLE PAVED 2 FAMILY STEEL - "ASB. SHINGLE — XIRT LOG CAB EX BRICK I TILE OILED UNGALOW CONCRETE METAL i SWAMP APARTMENT STONE BROOK STORE (� FNDTNS. I INTERIOR I LAIC F. STORE & APT. STONE ROOMS DAMS STORE & OFFICE ONCRETE I APT. ROOMS I SW. POOLS OFFICID AO f3LOCKS APT. TEN. COURTS GAS STATION BRICK i ATTIC'OPEN GARAGE PIERS i iI FINISHED I OTHER BLDGS. `EXT. WALLS PORCHES BARNS BASEXENT V WOOD y X FRONT SHACKS PART BRICK II X SIDE 1 COTTAGES FULL BRICK VAN. X REAR BUNGALOWS CEMENT FLOOR LOG {� A ENCL. I ELECTRIC FINISHED SHINGLE PHONE GARAGE B. IN. COMP. FURNACE FIELD: STONE Width D,eith Stories X. X X X x Type foundation, Room with window area ..... . Sewerage type Size of septic tank .. ,..: Lineal Ft. Drainage .............. Size of dry wells ................. Additional information: .......... . T'. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . this appl�icqtion must be accompanied by copy of surveyors map and complete plans, specification, and all information equired y. oning Or i a an Sanitary Code when requested by inspector. I, ........ the applicant do hereby a that th b Wst ements are rue to my knowledge and elief. Fee ° ' Signature of Applicant .... .... .... 1a,. . EX I i —,- - — I i I i i i - --�-.. i I- �:.T ti 77 T "�-E 1 1 p _: '1 4 T '4 [ - -.-. -� R� : ; � ^•, �I' l��'Y'1 �rr'� � t � :. -� .� �• � r -' �iY� k �, � 4� ���tw n� Y , � W7+� u� _ I }�_�t—!��K I � I t t F l ?yeC•�, 7 ( 1 ai'n -, �%�,a`+C �t4'r ^. ' T •r. ! .i;? i i �,fi•'i� �.., x�lwv',�YV^� •"�'�' I' I I I ;_. ,_ —_..__ _.... 7- ...we:r --. �. w. w..: w�...,.- ...R,.....w:....w.w..a� .. __ —_ lo.w,s..+.., , .�..�...•ti.- .w....n�•..... .{. . I i i I I i I ^~ I I I I i li .I I I , I , j 7 I , , I .._: -._ ... ........ . . ...:.— ___- ___ __... .. �.._,. �. � ..,..+ww- ._�..v..�...:.,.a. -... �t.�..::: -z..- .M...:: •. '...: xau .i.`:rYtd- i.su.-e_....L.'++...w ..uaaiw+a��� ... .. _._ _.. I I { I � 1 I i J ! f i I I _ e t , v - -- _ { ; , Er f E; I 1 I i I #`•, ► I u s ►.i .;. El fill. ,! t •f r�f ! t t_4 Date: kill i't�- Putnam County (Department of Health Division of Enviroamental Health Services SSTS Repair —Final Site Inspection 2W ' Inspected•by: Lj.-/ 1. Type of System: Conventional ❑ Alternate ❑ Comments: 2. Se tic Tank Y a. Septic tank size -1,000 ... 1,250 other b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. )[Distribution Box i. All outlets at same elevation (water tested) ... ii. Protected below frost .......... .................... iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box — ro erl set ..................... f. Trenches i. S stemcompletely opened for inspection ii. Length required Length, installed 'AP!F Installer: E�•S • N/A I . Comments iii. Pipe slope checked ... ............................... iv. Installed according to plan ..................... v. 10 ft. from property line —20 ft — foundations ... vi. Size of gravel % - 1 '/2 " diameter clean ......... vii. Depth of gravel in trench 12' min ' unum ...._ ..:.: , r .� ._.:..... _.... - wY......_... �sr..^.. rta.". s..... v;. wSi< W�. '[F^*w..�....W- .......p.-rvym�V VS.m.r -aa.., ro..e+W .-.sv a.aw...aM w.. +.gyp �Le+.._. Pi .:,.. °.a..�..a.I^...._..y��'Y..wn.O Yrrir.• ea ^i viii. Ends capped .... ............................... . Pumg or Dosed S stems 3. Sewa •e System Area a. SSTS Area located as per a roved plans . b. Fill section — c. Distance from water course /wetlands 4. Overall W6rkmanshi 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: 'Q vi r C4 lbsA5( RFS1 Rev - 011312 C0 PUTNAM COUNTY HEALTH DEPARTMENT .DIVISION OF ENVIRONMENTAL HEALTH SERVICES YES NCY Internal Use Only PERMIT # ❑U Repair Permit issued in last 5 years ` Not in Watershed ;e-Ilepair epair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated 1:1 within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review SITE LOCATION TOWN OWNER'S NAME S I I �a MAILING ADDRESS / I/ %L ) i APPLICANT `:2 t __r J a --1 N & Relatlonshlp (i.e., owner, tenant, contractor) DATE FACILITY TYPE PS. PCHD COMPLAINT # PROPOSED INSTALLER PHONE # ADDRESS �lOr� ��(,yf/l REGISTRATION /LICENSE # 1� Proposal (Include a separate sketch locating the ous , >roperty lines, all adjacent wells within 2001 -� feet of repair and the location of existing and proposed systern) r NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair.' /"� I — I, as owner,agree to the con itions stated on this form SIGNATURE Z T TLE DATE ah )ZT (owner) I, the, septic installer, agree o comply with the conditions of this permit for the septic system repair _ NATURE - V» TITLE DATE T (Installer) Propgoal gonroved with the following condi 'ons: 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 backfillejlnntil authorization to do so has been obtained from the Department Yor INTERNAL USE ONLY Proposal o Proposal ;De;nied �,Al InsDectWs Sionature-ArTW DaI6 Ex rat n Date in compliance with COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 1 I lea, L s 4 5) j fl VI it jf ii '-- STONEWALL (TYP. ) Y STONE PILE WOOD SHED ROOF, BURIED DRAINS VAULT \ CEO WOODY Ns< DECK 1 STORY 7ED TO, TIA CONSTRUCTION W OF PUTNAM VALLEY "WATER SERVICE LINE �Y CONCRETE ®L BBQ GRILL SLATE PAT10 —ASPHALT .._ .. > :• _.EOIVEWAY.._._, UTILITY POLE (TYP ) GUY —,,, WIRE A CORN LAYVE (A.K.A ROCHDALE ROAD) AJIJU F0, THE LAA in ArnRP