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74.10 -1 -29
BOX 28
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PUTNAM COUNTY HEALTH DEPARTMENT -.7"'
FT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'µ',
... �...: 'PROPOSAL FOWSEdlllAGE•TREATMENT SYSTEM REPAIR
NO// Internal Use Only PERMIT it / 1Z' J- -3 V
❑ (✓� Repair Permit issued in last 5 years Id' Ot in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ' 0 Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 43 Perk Drive TOWN Putnam Valley TM#74. 10-1- -29
OWNER'S NAME Matt /Jennifer Cichon PHONE#a2-8-8108
MAILING ADDRESS 43 Park Drive, Putnam Valley, .NY
APPLICANT Matt /Jennifer Cichon
Name & Relationship (i.e., owner, tenant, contractor)
DATE 11/3!11 FACILITY TYPE Pr i v Dwe 11 i n g PCHD COMPLAINT #
J Mantovi Excavating, Inc 628 -4528
PROPOSED INSTALLER d PHONE #
ADDRESS 485 K en n i c ut H i.l l Rd REGISTRATION /LICENSE # 1035/1036/1126
Mahopac, NY
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. 3g i y f i. y W 3
Replace old drywell with precast cement drywell.. Connect' to... _Y D6vigCt
existihn -pipe & disconnect existing drywell.
I, as owner,agree to the�conditions stated on this form
SIGNATURE
(owner) . .
1, the sedtieel
TITLE /> (,j �✓ P %' DATE l �/
.. - ...... - .. .. _
agree to comply with the conditions of this permit for fie septic system repair
TITLE Installer DATE 11/2/01.1
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.
INTFRNAI IISF eml v
Proposal Approved .Proposal Denied ❑
nspectoes Signature & Title Dat / Ex irati n Date
,Repair proposal is in compliance with applicable codes Yes Cd No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
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PUTNAM COUNTY DEPARTMENT OF HEALTH
..-,-.......-..,,DIVISION, O!.ENVIRONMEN-TALHEATIL,HSERVICiE.,$,.,,..
FIELD ACTIVITY REPORT
Tel:
Street Town State Zip
PERSON IN CHARGE
Name and Title
TYPE OF FACILITY :
9 a s ( -§:: 0 6---
FINDINGS:
TPT
Signature and Title
RFPQRT'R'P.C-FTVF-r) BY.,
I acknowledge receipt of this report: SIGNATURE:
02/96
Rev.
Title:
PUT.,N.A-'vf COLNITY DEPARTAENT OF HEALTH
DIti-ISIO,NOFEiN�rIRO-,N-.,'Y[EiNT-kL HEALTH SERVICES
DESIGN DATA SHEET —* SUBSURFACE SEWAGE TREAT�MENIT S YSTEN-f
Owner: zr.--?VO-A/ Address: FAIZR 2gjVr--
7#,/0 2-47
Located at (street: TM Section:
Bloc" Lot
Municipality: 71 r ZAM L VAAL-E-x Watershed:.—
SOIL PERCOLATION TEST -DATA
Date orPre-soaking,
Witnessed by:
Date of Percolation Test:-
Hole No,
Rua No.
Time
Start—
Stop
Elapse
Time
(min'.)
.)
Depth to
water from
ground
surface
Start - ,S top
Water
level drop
in n inches
Percolation
Rate
miniinch.
2
-.3
.4
2
4
2
r I
4
- I
s l I I
I I
I
I
l I I i
I
2
4
Notes:
I T-IZ77 rn ip -,ir -jPnrh 1tnr:1.1A— ,,;—,-;w --! --, —
I t:
gEscluPTIOIN W SUIL6 LINCO !N-I LF-U) TN (D E 5 — _--------- - - - - --
F, 0 L E HOLE
HOLZ HOLE HC
I.V
I
2.0'
2. 5, bow
d-
4.
4.
5.
-7
G.5
Lridicate!evel at wiich gound-waieri is encountered
Indicate levet at w1uch mottling is observed A/,ed
Ir
Indi- C e I.ev�t to ;VhIch water level, uses e,.-r beingg encountered
Deer hole observations r-,,adp- by: Dace /,I/;-
Design Professiorial vane:
Address:
C, ,
� i c n, at-u re:
Oct 26 2011 2:47PM HP LASERJET FRX _- P. 1
PVTNAM COUNTY DEPARTMENT OF HEALTH
DCV'XSION OF ENVIRONMENTAL HEALTH SERVICES
"QY. UT,FQR. FIELD TESTING
'Gene Reed
ATTENTION: Q Michael J. Dudzinski, PE G Joseph S. Pararvati, Jr.
All trformatton muss bed coinpiazed pHor to any scheduling. Date: October 26, 2011
Engineer or Firth: I Mantovi Excavating, Inc. DBAIMehopao Septicphone It: 645- 628 -4526
Reason: Deeps D Item F0P- p�Ry l4
Road/Street: 43 Park Drive
Town: Putnam Valley Tux Map t: 74.10 -1 -29
Subdivision; IAt* 10
Owner: Matt Cichon
0 Prgiect not within NYC Watershed
t1YJ;2! CR3 R'El[tIA FAR J(EZN� Q%F F $014 TESTI' f,
VES /Psairosed Ssi'5 within tfie t}rattmge basin of West Broach. Crotch Falls, or Royds Corner
' / 'reservoir•A.
[[[[}} Proposed SSTS within 500 tleet of a reservoir, reservoir .tee► or control lake.
0 _• �'tvposad_Sgrg within 200 fact of a watercourse orn DEC wetland.
_ .... _
.. �[ _ , ma W SETS- deSftn.liar:. grrtttge! on 1l±I1�0.�eFl4iie /d�Y ar Dcsl er
p Proposed SM for a Commercial Project.
it is tite're%porsibility of the design proressk►nal to provide ttffi above intermatioa prior to soil testing.
This Departum t will determine the NYCDEP pcolect statue (Joint or Relegated) bawd an. the response.
IY you answered YdA to any of the questions, MYCOEP enudt witneo the sell tests. This M- purlment will
coordinate ar mutually suitable time for field tasting with the Desigw Profoulons and NYCDEP.
Ir a project has bee* dotormined to be Delegated based on tba, above reitt non ood then subtt"uent
lntortuation tndtcates NYCOEP is required to witness the soil test,, It wm tip the sole resoonsibillty of tim
deslgo protessionol- to schedate re- wttnesieng of the soil testing with NY- CDU''.
FOR COUNTY US12 ONLY
f.�.l�1jd J
rricLoTp,"ti
32
IDES
tnam Golf
and
Tennis Clu
ma oWN II
% '77
0 Lie I
V
S
Bryant 'i
Lake
-P
Ce
30 P.O.
30
Aft
GRID
STREET
GRID
STREET
GRID .
t#13
STREET
GRID
STREET GRID
Barger
Pond
15
8A
60A
P.
.33
Golf club
%IsGrrut
Lake Mahopac
,'Canopus
Island
1 AE
33
O.P
G, .9
A
S
co
loo ei� cw
All,
U
Teak e
Lake
mahopa6
PEEN 5 B�`t, Bdddwin a
S. C..
I E
;0
6N BIRDSALL A INDEX TO
0
MUNICIPALITIES IN PUTNAM COUNTY
ER
St EXT
MUNICIPALITY GRID
EAST OSCQO
Brewster (Village) .. ............................... N7
Carmel (Town)........... .............................J7
Cold Spring (Village) ............................ B7
.............
Kent(Town) ............................................ J4
Nelsonville (Village) ............................. B6
Patterson (Town) ................................... N4
...... . .....
Philipstown(Town) ................................ C9
Putnam Valley (Town) .............. ...... E8
tTown ..................................
PUTNAM COUNTY ZIP CODES
Copyright 2004 Hagstrorn Map Company, Inc. All rights reserved. No part of Brewster ........... ............................... 10509
cr
this work may be reproduced or transmitted in any form or by any means, Carmel ............................................ 10512
electronic or mechanical, including photocopying, recording, or by any Coldspring ...................................... 10516
information storage and retrieval system, without permission in writing from Garrison ........... ............................... 10524
the publisher.
Lake Peekskill ................................ 10537
The information shown on this map has been obtained from various Mahopac ......................................... 10541
authoritative sources. Nevertheless, a work of this scope may contain some Mahopac Falls (PO Boxes Only) .. 10542
inaccuracies. Any errors and omissions called to our attention will be greatly Patterson .......... ............................... 12563
appreciated. Putnam Valley .. .... -- ...................... 10579
REA SEE HAGSTROM'S UPPER WESTCHESTER COUNTY POCKET MAP
STREET
GRID
STREET
GRID
STREET
GRID .
STREET GRID
STREET
GRID
STREET GRID
I STREET GRID
STREET GRID
STI
Butternut La
N 4
Fulton Of .................
R 4
Marshall Rd
R 4
Somerset N 4
Arden Or
0 10
Foreman Rd Old Albany Post Alta Ad ........... D 10 1 Cour
'C
............
Caldwell Rd ............
C
0 4
Gardiner .................
R 5
McManus Rd N
N 4
Sonnet La ............... N 3
Atonement
C 9
451 n 7 1 A--
Forest La Rd
Ca verton Rd
A 14
Garfield Or
0 4
McManus Rd S
N 4
South Birch Hill Rd. 0 2
Avery Rd.. ...............
C 8
Fnrc—,Ale 0•
Camden Rd ............
R 4
Garfunkel Way
N 5
Meadow Ridge Or
P 5
South Ouaknr will
^' ......
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