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HomeMy WebLinkAbout3644DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.13 -1 -23 BOX 29 03644 talml-k ME I'll 6 71�� r 16 - ; jr -' : r 'Jim IN 03644 Y �o $(�� ZY 4-0 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES No Internal Use Only PERMIT # - ❑ Repair Permit issued in last 5 years Not in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION gq, 00 0&I�CCQ -:S WN VTIVItktyAL��Y TM # ° /` 13 - 1— 07 3 OWNER'S NAME :�- j RF_ g i4pup uus C 0 -®P S9Ci6 ITY PHONE # C/O i Fr S_Z --W9 t MAILING ADDRESS ReCADIiLr Rm 1 L4iE >iI '�f APPLICANT v w 6 p.0 6R A G F_ f_- _r �I I Name & Relationship (i.e., owner, tenant, contractor) DATE 6 i S 1 o FACILITY TYPE 1� 5 P tP�T Ay"' �7 3�y7 PROPOSED IN�T�L LER ,p WO+PD (5P-A Ct i5PL7_ PHONE # �'� 5- S46 -d,51 ADDRESS i,-r- N 4 AA VA LLOw !mil � , REGISTRATION /LICENSE # /0 105`797 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,agreA4q the conditions stated on this form SIGNATURE �i .0 AM0 Z4' TITLE 46614-1-60 6 614 -1-60 if DATE 61, �;- /J o (owner) I, the septic installe agree to comply with the conditions of thiiss permit for the septic system repair SIGNATURE TITLE. IT6 0 -9 r DATE (installer) Proposal approved with the following 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 backfilleed until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Q Proposal Denied ❑ V,,kf]Er, EX d116 ho In ector's Sig-natufb & Title Da a Expir tion Date Repaairproposal is in compliance with applicable codes Yes ❑ No ff- COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 rll-}r E ,- AX-voccl--s PU 14J - ..Y PAP RY44cc 5trgr, w loo0 6 � INC. oc, — io ' 0�00� 4c- 17` i3c_ IT, co HO E e `s ft/ t4fz,4 m:o i 8�6g13s3y> PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES IT :=; -A "O ION TO CCO TRU A k VUEL T T � _ .. please print or type C�i} - em# .. �x ,7�._ WA Well Location Street Address: Town/Village: Tax Map # nt v4"1149 7 / ' Bloc c, r �✓ (�a Map Block Lot(s) Well Owner: ame: AV–e "'rr (fevPzri;J Address: ue Arl a-/ y/ Phone #: / ©�,.es Use of Well: Residential Public Supply Air /cond /heat pump _Irrigation 1- Primary . Business Farm Test/monitoring Other(specify) 2- Secondary Industrial Institutional Standby �v+ Yom) Amount of Use Yield Sought gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason !(,Q {'r ((; i--h w .7ix S xo ' for Drilling -r T f (.d i h '77, '4?o`S Well Type Drill 6d Driven Gravel Other Is well site subject to flooding? ........................ ......:........................ ............................... Yes —No Is well located in a realty subdivision? ........................................... ............................... Yes No ✓ Name of subdivision Lot No. Water Well Contractor: of,, a w- -tu S C) i'l Address: 4�_3,_ ✓ . Is Public Water Supply available on site ?............ ..................... Yes _ No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on .separate sheet/plan. Date: 3 �6 �! Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Departmel take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam u y. Date of Issue Permit Issuing Official: Date -of Expiration '3%2J a o /2 Title: 2, bl j -,�_ H2a. 14.4% C Permit is Non - Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 I i OWNER'S NAME 5�°�8 b6 a�a9J PUTNAM COUNTY HEALTH DEPARTMENT�I�� DIVISION OF ENVIRONMENTAL HEALTH SERVICES a®oA FA-RGrca 5TTOWN Pv -tAl bton 4LL1�y TM # `114ece Pro, P4 ty.5, C 0 - 010 So G/ E-0 � N C • PHONE # ��" ��S- ✓�Z� - o7J"'� j' MAILING ADDRESS 6L R o G1-1 DA LC APPLICANT f1- cdtp Name & Relationship (.e., owner, kenant, contractor) DATE (o 5f- 1 ° F CILITY TYPE 1� �S PCHD COVP�NT #��_ PROPOSED INSTq-LER n�tJ�i d7 �(L� 6r4c W- PHONE # 9 'S r L� .2" F (� G $ W ADDRESSy�wle3rYt U qtr Z4 , ft--3f, REGISTRATION /LICENSE 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. C,(- A fJS e 0 S -7' —o Cc - `73- -41= +vu / IN C_ W j b 6 6 C,+ e- 1, as owner,agree to theB conditions stated on this form SIGNATURE TITLE 74kIZaT Cd1 ` O)P DATE (owner) - -I,-the septic-ins ifei; agree to comply with -the conditions`of t-- permit-fer the septic'system`repair ` SIGNATURE TITLE � DATE 1 S a C� (installer) Proposal aoproved with the following 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. Proposal Approved tture & Title �- is in compliance with COPIES: PCHD; Owner; Installer PC -RP 99ML INTERNAL USE ONLY Proposal Denied codes /e55 Date Yes ///0 on ❑ No Rev. 2/07 Soc') Cr F, -C T k �ft (I L, r- 7C2, -2 3 PAP (,c -r- New 1000 619 -c- INC :? *Voo pt v 8 Wc Lomyv [IJ W JE 0 I- -r,4 ®c SCs 6 02 &cilpgcr- R4 WAR-9 GF-9967EP:7- W I) F c.(.r-- BRUCE—K.: EEY- _. - Public Health Director ~ Merle Bogin 176 E. 71 st St. New York NY 10021 Dear Mr. Bogin: DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 July 1, 1999 Re: Addition- Bogin - 36 Rochdale Rd, Three Arrows No Increases in Number of Bedrooms (T) Putnam Valley Tax # 74 -1 -5 & 74.13 -1 -23 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 July 1, 19993he addition is approved with the following conditions: 1. The total number of bedrooms must remain at Two without prior approval by this department. 2. The area of the existing sewage disposal system, and its expansion area, must be 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. ML:kg cc: BI Very truly yours Michael Luke Public Health Technician BRUCE .K.- R..- F_OLEY.._ ,. '' public Health Director t DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road' Brewster, New York 10509 Tr— Tel. (914) 278-6130 Fax (914) 278-7921 PROPOSED ADDITION APPLICATION (RESIDENTIAL ONLY) l TOWN / r' - r STREET 14f E " lbw S TO v� / � TX MAP # 744 I NAME ME$4LUc f3)o nl PHONE 731 -�oq4 PCHD # MAILING ADDRESS 1i6, t_F , -71 Nak) *W, ]y (• 1 a D 2 1 DESCRIPTION OF ADDITION 6n/t- 1n DOci"l-Q . 'rDT7�i- 14 U P> NUMBER OF EXISTING BEDROOMS PROPOSED # OF BEDROOMS S, PAG (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., 4 Geneva Rd., Brewster, NY 10509, 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 of proposed floor plan (drawn to scale, with name, street, and tax map #) * 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. OFFICE USE Comments Feb 98 .P .. .,., s. DEPARTMENT OF HEALTH Division . Of Environmental Health Services 4 Geneva' Road, Brewster, New York 10509 (914) 278 -6130 Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Gentlemen: BRUCE R. FOLEY, R.S. Acting Pdblic ;Health Director Re: �C&nJ H MC- I TffIZ'9:-= Residence Tax Map -74-1-C '71- Town 2y— tg*M1 V&Ll,�,-1 According to records maintained by the Town, the above noted dwelling IS f IS NOT in coyliance with Town code and the total number of bedrooms on record is . This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: v OTHER e'�il. Building Inspector It PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES _. •~Gn, r.._s.9 9a t9 . y^ . v►•.+n 9 -, as.Y.t .. �9.. = +r . .s a♦ x . PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR ' OFFICIAL USE ONLY R I 1 SITE LOCATION , `- TM# OWNER'S NAME_ MAILING ADDRESS t? mac, PHONE ,. p�' �o.�- �/s ��� % <71 � Yff —0009 , 41 ( 0 ,,J", PERSON INTERVIEWED^ PCHD Complaint #• .Name & Relationship i.e., owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER ,3X�c �es ©►�'+��- PHONE S tl r 0 (00 ADDRESS +►' REGISTRATION# Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of p opos�al � from license� d p io fes i�on� al en ineer r r gistered architect. AUK 1A COcziot--, 2s.avzner ent f vner agree to the conditions stated an this forul: SIGNATURE TITLE`� )ATE Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b.. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML S /DATE/ 4 1 H 1 ti 9 1 0 z �.0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR F0RM. SECTION A: GENERAL 1NFORiVIA.TION Name of Project 7 P' �" TM#, Year of Construction Size of Parcel SECTION •B. TOPOGRAPHY (Please check all appropriate boxes) 1. ❑Hill Y DRIng OSZteep Slope ❑Gentle Slope ❑Flat 2. ❑Evidence of wetland ❑Low area subject to flooding ❑Bodies of water ❑Drainaae ditches Mkock outcrop S NO - Property-lines evident? _ .❑ _..._ -lam_ :I 4. Water courses exist on, or adjacent to parcel: ❑ 5. Existing individual wells within 20 OR of the existine SSTS? ❑ ❑ SECTION C. EXISTING SUBSURFACE SELVAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing, SSTS area.. A. ❑Level ❑Gentle Slope ❑Steep slope B. ❑Well drained Moderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) 13 Extremely limited ❑Somewhat limited ❑Adequate ft x ft 0 C N n f^o ,ti/J S Y Df ve HOUSE c 4 &`4 l -n Q- I-- ------ ---- -- ----- -------- ---- -- - ----- ----- ----------------------------- (1) Indicate location of SSTS A. Size and type of septic tank gallons r1letal 11 Concrete CIPlastic B. Type of absorption area 1.. Fields ft. 2. Pits. 3. Gallies (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXIS7ei WATER SUPPLY MPWS ar ell andividual well []Drilled ®Dug ®Casincy above ground CONi Uv ENTS : � s -� u C� -s� - S i CQ' �h e,*p sue/ �e d ra (� f REPAIRS ONLY: As Built Inspection Required: Status: As Built Submitted: As Built Inspection Done: Inspector: n i _I _I scueu tno cP All lxcBY - -_ - - -- P!0 63-2-4 - - - - -- n' 1 2S � 12 r 27 _ ,, 24 �zu °+r@ 47.80 AC. CAI. � r 1i 8.36 AC + a L 31 N - C" 4.28AC 20 22 9.02 AC. ys � j 9 - 'kg 602 AC. 416 3.24 AC. • B yJ -- - -- �, PP /0 63.3.51 16.28 AC. CAI. �f- - ` POND 1 1 lO \ r ROAD - � � 1 134 v z 1 74.06 IJ I � 74. 10 I� I � � I a r I I I � I � 74. 14 I I I I I I r I I I I f I I f / !I 74.18 / I NFORMATION Mn LINE OINVtp Miff M A1fTrIR - -111 1 'I LM -- @AMMO IliBT Ait 41AI v sfs 01 rar LIK nllAfC lIK ----� lnNMrnlil Al 40a Llfvlr — — -• frltlt 41fiA1<t 1 MIa91t1 \IK YJaa Olf @iCl lv ° � , tf T!a r9.N � r 1i 8.36 AC + a L 31 N - C" 4.28AC trz 4� �OIAG ys � j 9 d 3.24 AC. • B 34 33 7.59 AC. d i 9,13 mu 14.09 AC 15.80 AC. l 6 aa1 h,b 1 � C 3.20 AC � ^ 8 � fnw can s / 74.09 74. 13 1 I j II I 1 11 90.53 At- CAL. Ift I ^I 74.17 + rl fWM.k 4� If Bfsr,,q , s Y i! M F ASSESSMENT PURPOSES ONLY REVISIONS SPEf NO TO 8E USED FOR CONVEYANCES JI MES rRILID P W. SEWALL COMPANY nw< L 147 C LATER I STREET, OLD TOWN. MAINE 134 v z 1 74.06 IJ I � 74. 10 I� I � � I a r I I I � I � 74. 14 I I I I I I r I I I I f I I f / !I 74.18 / I NFORMATION Mn LINE OINVtp Miff M A1fTrIR - -111 1 'I LM -- @AMMO IliBT Ait 41AI v sfs 01 rar LIK nllAfC lIK ----� lnNMrnlil Al 40a Llfvlr — — -• frltlt 41fiA1<t 1 MIa91t1 \IK YJaa Olf @iCl lv