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HomeMy WebLinkAbout3729DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdoc;s.com 631 - 589 -8100 74.18 -1 -14 BOX 29 rM 16 J or IT .� � moo . 'T� ' r �r LLI 037291 PUTNAM COUN'T'Y HEALTH ;DEPARTMENT DIVISION OF ENVIRONMEWAL 1ffERLTH SERVICES �7�/�;;�'{{//�� '�yyam�'!! T_, 225 -03�1e 0 �.,7� WI? q7 �/ ,•� �, - . .,,.. �L�:Ji"tii'.AL --1, VUM.Ut� D.!' S :i'S.Xi %L �4i�l�Ell. 11; �liit CWNER'S NAME AfJI�� r'lC ,atii t-�E. PHONE SITE LOCATION Pcxr'�la..M 'S/s• cIf TNl ! - 2 •'Lq, t> MAILING ADDRESS 2(0 ^Ffle; ,gT Pi... t 1 �P�oPPtG r•l't' 10541 PERSON INTERVI3gED PCHD Complaint # N m &.Relationship (i.e, owner,,tenant, etc.) DATE _ TYPE FACILITY ONE f AM1(_ -( J3Efi,1 pe'rj Fs PROPOSED INSTALLER J i t-I jAe gM 606e=MR&c. cnv PHONE Proposal (include sketch looxting 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 proposal from licensed professional engineer or �. registered architect. � � �� � ;r.1r � r ��' •r �� s �" �• �� i ar �� ` -ter �L Proposal approved Proposal Disapproved Proposal approved with the followincr 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. Date c. Location of installed pcmponents 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 drywells surrounded by one foot + gravel). e. Installer's name and a miber. 3. System repair to be perfamed in accordance with the above proposal and conditions. I, as owner; ° or reported a%mt of 0 agree SIGNATURE to the above ,con tions. TITLE ,����% .. /..i; <.� � �- GATE � DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 March 20, 1991 Mr. & Mrs. Hegerty Proyost Place Putnam Valley, NY 10579 Re: Proposed addition Hegerty, Proyost Place (T) Putnam Valley fS 65 -2 -23 Dear Mr: Hegerty: JOHN KARELL Jr., P.E., M.S. Public Health Director I have received and reviewed the plans for the prol:csed addition to the above mentioned residence. The plans indicate that a master bedroom suite, approxi ately 269 x 269 and a new kitchen approximately 23' x 15' will be added to the existing ridence. One existing bedroom will be'oPen to the hall and converted to a den. The survey indicates that sufficient area exists to expand or repair the sewage disposal system, should it become necessary in the future. Therefore, based on the information submitted, the above mentioned addition is APPROVED with the following conditions: 1. _ The..;tot.al: number oF_ bsd:=•=ms- most remain at three without prix: approval ri "apartment. :- 2. The area of the existing sewage disposal system:, and its expansion area, must be maintained. 3. All plumbing fixtures must be replaced or updated with water saving devices, i.e.; flush toilets, restrictors for shower heads and faucets, etc. 4. The den must have a minimum 60" opening to the hallway. Approval is granted for sewage disposal only. 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 Sr. Public Health Sanitarian WH /JP cc: SI (T) Putnam Valley PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONME14TAL HEALTH' SERVICES DESIGN DATA SHEET SEPARATE SEWAGE DISPOSAL SYSTEM PILE NO.- Owner Address Z-:: ___ 0?'Z^ - 2 - Located at ( Street ,Y C Sec . Block Lot (Indicate nearest cross street:) Municipality Ox., y41_'r/ Watershed —04 SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATION Hole 4 Number CLOCK TIME PERCOLATION PERCOLATION Run 2 11C Elapse Depth to Water Water Level 4f No. Time From Ground- Surface in Inches Soil Rate Start Stop. Min. Start Stop Drop in Min/in.drop data to be submitted m'itted for.. review. 2) Depth measurements to be made Inches Inches Inches k L 3 '7 7 5 4 5 2 11C 4f Notes: AC 7- 3 1) Tests to be repeated al_" same d6pth until 4. tained at each percolation test Ai- data to be 4 5 2 3 4 5 Notes: AC 7- 1) Tests to be repeated al_" same d6pth until approximately equal soilrate s ar e tained at each percolation test hole. All data to be submitted m'itted for.. review. 2) Depth measurements to be made from too of hole. k TEST PIT DATA REQUIRED 70. BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES \. _ _ .o - «.... ;-.:.,c„�.�_s- Q DEPTH s - :..r- .�.._f _ .. . ti.'.i - •, ... .. HOLE N0. '.i J�. "`: " '. :. .. _ .. • = rv.-w r,•rs..vY. r .HOLE NO... ' • , .. .. HOLE NO _ _ L/ .. G.L. 6 rr ii y h L�j ` /xT�4' ��rry�� �l 1211 `� ,s,'� `' CJ`�J ±cr✓ i`Tr'U L,CJ� %/��1/.� r ✓��'� r 241? ti 30 IT 6j 3611 L 42 t1 if MD S 41f _ 6 Orr 661T 721T G/ L, j� 7811 sI J4. INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED /A/6 INDICATE LEVEI, TO WHICH WAT7 LEVEL RISES AFTER BEING ENCOUNTERED, g TESTS MADE BY �- 14 "Vpf0z- Date �i'� DESIGN Soil Rate Used -t;5 Min/l" Drop: S.D. Usable Area Provided No. of Bedrooms 1. Septic Tank Capacity G�� Gals. Type 4►.,c.- Absorption Area Provided By 7J L. F.x24"_36" , ... width trench. Other Name STANLEY I LANDED Address BOX 267 ��� �L�Y j' �Md L f AMAWAIK, N, Y_ inml PUTNAM COUNTY DEPARTMENT OF HEAT H �r9jF No, 32�Z�`b Soil Rate Approved Sq. Ft./ Cf N by Date cashin associates, p.c. design professionals routE! 52 carmel, new york 10512 (914) 225 -8088 - LETTER OF TRANSMITTAL !DATE JOB�!%C. < ATTENTION RE: � E y 70 A,- WE ARE SENDING YOU Attached ❑ Under separate cover via • Shop drawings ❑ Prints Plans • Copy of letter ❑ Change order ❑ the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION p fO?- '* ew C% I -- 1✓ STS �� r�O�- r' tj C--tp t!: Flo f�l ST�r� �� .J • L..AfivL� 2 . E . 32.720 THESE ARE TRANSMITTED as checked below: XFor approval ❑ Approved as submitted • For your use ❑ Approved as noted • As requested ❑ Returned for corrections • For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO: • Resubmit copies for approval • Submit copies for distribution • Return corrected prints SIGNED: - jcW ` If enclosures are not as noted, kindly notify us at once. L-.F'. b� kk � x_t ^. cu4law. Co U-nT Uepar "8At uZ nNal t}, iI ivisio of E vironmonta Health Sezo4ou tit � p L t t� �I • iTin! ! i t i It :•. s'e' ^� ! ' + � f' : a- � •at�P �,� . iKr�•t4 ..�•�+....:. :� f ' .. � � z4?l'el:ik� ..#��:i l rii�`b��Y...6s.'. :1qf ♦ id i a; � P,� xr$ " �" n tr7 F:.: i j igN t z s 3; t; u� t tk i s t• of i rt' IL 3; t; u� t t' f` h J'. t' a, y a' a t• of i rt' IL I., 21 _q .... 17r I I . Of Ar� Nz.,/ WPRCWD--� T, SEP.161971 KAM n OF MEIITAI HEAL"' /L ...... . rn U. n. ,)Ivision)f Env-jTon . ental H serviob. 'r Z4 W,oe fol-PIM-\ 01-ILL-e-C :a //-� C. I\pproved a noted for oonformanoe with. yp 6 I> - 2 - �Zlll itpplicable lules'an,a Reg4ations• of the Putnam County H6alth;Dep*ztmeni.. d at rag Consisting of 'hal� S4tk Tank `3 all '.Feet -Width trench XAAQ Ad ss dr Ha s Erosion Con. ol,.: Been, Completed? ti Ji se ve Fe, eoel low- Date a -arld Such approvals are available and the aporov6l.of'the privat me null o i d When a public - Watit -supbly *becornes available. suc subject to modification or change wfien, A f the Commiqc oner,of -Health �ch re t- 6 modificati" or chano�, is -necessary. Date B / gACTrERI IODER ML (Agar plate count at 359 C). COLIFORM'GROUP (Most probable' No'. /looms.)' .` HARDNESS', TOTAL ppm -„ t-t4 ^i R 4 AS T. DETERGE TS PPM' t s`x;z �; NITR4,TES (cts'N) ppm IRON TOTAL ppm o Q{ WELL COMPLETION REPORT 3/71 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK Thls:'re g-+ �sjto. be C�fTlplPte�l by.��ell.d�lller_andsubmi *. #ed to. County Healthy Qe��r meat together v�ith, labora *.off. analysis of water sample indicating water is of satisfactory bact0ial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NA AE tom+ at ADDg LOCATION OF WELL %(No. It Street). (Town) (Lot Number) JV �i°j ..s -r PROPOSED USE OF WELL BUSINESS © DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ EST WELL SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING (S(Specify) DRILLING EQUIPMENT COMPRESSED CABLE OTHER ❑ ROTARY AIR PERCUSSION ❑ PERCUSSION ❑ (Specify) CASING DETAILS LENGTH (feet) r�r J DIAMETEF:(lnches) 'rf WEIGHT PER FOOT / "� THREADED ❑ WELDED DRIVE SHOE RYES ONO WAS CMG T JU ED? MYES l_J NO YIELD TEST ❑ BAILED HOURS G.P.M. PUMPED COMPRESSED AIR YIELD (G.P.M.) WATER LEVEL ' MEASURE FROM LAND SURFACE ­STATIC (Specify feet) DURING YIELD TEST fleet) Depth of Completed Well y p in feet below Land surface: SCREEN MAKE LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (inches) IF GRAVEL PACKED: Diameter of Nell including gravel pack (,Inches): GRAVEL SIZE (Inches) FROM (feet) TO (feet) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. FEET to FEET n•` �s tom' sr 1 I t If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED DATE OF REPOFI WE RI ER ( ignatu e) Owner or ru�rcF -user of Building OMuni cipali.ty fC. '� , A o Bdilding Constructed by Location- Street Block Building Type Lot GUARANTY OF SEPARATE SEWAGE SYSTE14 B, I represent that I am wholly and completely responsible for the location,- workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards,. rules and regulations of the Putnam County Department.of Health,. and hereby guaranty to the owner, his succes- sors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of initial use of the '§ewage disposal system, or ariy repairs. -rade by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occu- pant of the building utilizing the system. The..unde.rsigned further agrees to accept as conclusive the de- termination of the Director of the Division of Environmental Health Ser- _- 'vices of the Putnam County Department of -y3�.a,ltr a.:s -to whether or not-- the failure of"the system to operate was caused by the willful or negligent act of the..occupan"t of the building utilizing the system. Dated this day of 19 -71 Signature o Title If corporation, give name and address) THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF.COMP,ETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Envirom'ental Health Services, Putnam County Department of Health .' > PUTNAM COUNTY DEPARTMENT OF HEALTH + D /b!SIOn of- Environmental Health Sei' es Came% N Y .10512 'CONSTRUCT.ION PERMIT' FOR SEWAGE -DISPOSAL SYSTEM ��N�`R _J�r4c.�• t1f ® Town or e ? O; m Located�at fiO Q-6 p=ie �eC*��� x P %� 05 ,Rio Subdivisions Lot Job owner /�/l1CI,C'1. 1,2 A13A`/y Tom: _ Address oOL±/5't3�tvimPii/`4 ! . Building .' YPQ /C fig' /Ue� i� �lL? L Lot Area Number -of Bedrooms Total Habitable Space ��� �`'��� Square Feet 1 Separate ,Sewerage System to consist of GalSept�c Tang �'' 1 % lineal feet X width trench To be constructed by D 5'C�� c �� Address 'Water SuPPIy:- Public ,Supply From Private ^'Supply fo be drilled by yam' Address K C Hwy Other- Requirements G� Di91 --in i� '.5Y✓�% 17' 1 represent that 1!am wholly andreompletelyrespon s�o Sd$s '. on of `the proposed system(s); 1) that -the separate sewage .disposal system above described will'b'e constructed as shown'or Lh mend - and in accordan`ce,with the standards; rules an: regula ions o the , u nam County - 'Department- of. Health; and that on co' e. rti Constructiori Compliance satisfactory to tfie Commissioner of Health will } be submitted' to •the=Department . and a - Niritt 1 8 d�il :vii = f nish_ owner, his succes ;ors, heirs!,or assigns by the.builifer,.that'said . builtler will ' E place'• in` gootl - operating condition any pair t o s�i se + sfe 90 ing -1 he period;of two (2).years immediately; following the Cate. of the issu- _Co ru tion j3tWM tl or anal ` system pr any repairs t`hereto;'2)''that` the drilled;w_ell described °above Willebeflocated as shown on the aertif,catep ii an t said ett�WiCC tall i ac rdance;- w-th`.. th standard rules and regulations 'of the Putnam pproved la County Department of Health R A Date ! / PEA•- � Address _. v�2� �y- License No APPROVED FO,R 'CONSTRUCTION This; approval ";expires, om tfie date issued unless; construction. of the building .has, been undertaken and is .revocable; for.'cause, or- maybe amended o[ modified'.wheri eonside' ecessa- by:the Comm ssioher •o Flealth, Any ,chanye`or alteration of construction requires new `a' n . � pepmit.. proved for disposal of domestic ry sewaCge �� �Si�li_,water ply ohlY it Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH;SERVICES .s.c -: -..7 • � '.,i �•._.. .4t -.a '-- fa- :'."°•"4 _ . Ewa -.._n v+. -� +! •• .- t•IY' __... . •. . ...'.• DESIGN.DATA.SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner /�', �;r�/,� ✓' P� q 4?1+,V7 Address ]Jav lfr�,� -, :, Ale. �yy y4,V1-dre 1 A/- y! Located at (Street) c�� �..; f 4,. C. Sec . Block Lot (Indicate nearest cross street) —�- Municipality %on y v,c ler,v 2 )"4GLeY- Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATION Hole Number. CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Water Level No. Time From Ground Surface in Inches Soil Rate Start Stop Min. Start Stop Drop in Min/in.drop Inches Inches Inches _r G 4 5 2i�;/ s 4 5 1 2 y. .r %%S 1,7 4 C- s Notes:' 3/«(I°�i c� �' T� it KAe 1) Tests to be repeated at same depth until approximately e tained at each percolation test hole. All data to be sub 2) Depth measurements to be made from top of hole. al soil rates are - tted for,,.r.eview. . 84t? if INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL, TO WHICH WATE� LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY '0- 4.4fOVD£0z- Date r-' ✓� �' l� �=' Soil Rate Used -,J o Min/l" Drop: ,S.D. Usable Area Provided.. ! �•+�'� kJ No. of Bedrooms ,j _Septic Tank Capacity da G✓als. ( Type��- cas/ /- .,,n.�.�.: Absorption Area Provided By L.3 ,J L. F.x241T 36" i,--" wwdth trench. Other Z- Name STANLEY I IANDE ss Address B O 26,7 �EcO �y�x �. L A 1, r' PUTNAM COUNTY DEPARTMENT OF HEA H Soil Rate Approved Sq. Ft. / N� by Date TEST PIT DATA R- tQU+REccD I 0 BE STUBM.ITTED WITH APPLICATION, Y .•. ...a.e -_•r!- -. .r .. ..,,. ..,�.: -T r'irJY�.. C;D qs [�ry�.. 7. r C��_: ..,- �. •1'E . -ST-t- 1--GLE -8 DEPTH HOLE N0. HOLE NO. HOLE NO- G.L. /pf� �7;<: ��> �•- 'f� -sic _: 1211 J<3n; L � � � ; <'� � eJ�,� 1 scT• �C= �../�i; ,� L l.� =' � /x.,i'J� ��- 1811 24 rte" ti 30 3611 4211 48 t? 5 411 6 01? 66" Lr 72t? 78 84t? if INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL, TO WHICH WATE� LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY '0- 4.4fOVD£0z- Date r-' ✓� �' l� �=' Soil Rate Used -,J o Min/l" Drop: ,S.D. Usable Area Provided.. ! �•+�'� kJ No. of Bedrooms ,j _Septic Tank Capacity da G✓als. ( Type��- cas/ /- .,,n.�.�.: Absorption Area Provided By L.3 ,J L. F.x241T 36" i,--" wwdth trench. Other Z- Name STANLEY I IANDE ss Address B O 26,7 �EcO �y�x �. L A 1, r' PUTNAM COUNTY DEPARTMENT OF HEA H Soil Rate Approved Sq. Ft. / N� by Date ter. PUTNAM COUNTY DEPARTYIW T OF HEALTH ;.: , ., . - ,-. ,.. , . _... = �IyS�Olv:..vP,::Ei �l� _... ,,.,,. r�,.,,,..•T_ -, �,z;.:.,,; z .. �_ ....._ ..__.� . _ v ,.�ir1i,�N�ri.� -r��AL�� •.��Rv ��.u..•,...- ..._. _. .... :... A Date '= 1 i v Re: Property of Located at Px"Ovos; f 6..g Section Blo�jck Lot y Gentlemen: �1 This letter is to authorize STANLEY I �o ©® a duly licensed.professional engineer or registered architect (Indicate) to apply for a'Construction Permit for a separate sewerage system; to serve the above noted property in accordance with the standards, rules or regulations as promulgated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems i-n`coniormilcy with -the 45 „:! . -- - 14.7, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, Signed r Owner of Pr6perty Countersigned: �� `�" Address P.E., 9 # Telephone ( Sea ,�pf �1 V V 'BRUCE R. FOLEY Acting Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road January 8, 1998 Ann Mercadante Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 Patricia Marshall 26 Provost Place Mahopac, NY 10541 Re: Addition - Mercadante/Marshall 26 Provost Place No increase in number of bedrooms (T) PV TM #74.18 -1 -14 Dear Ms. Mercadante/M.s. Marshall: I have received and reviewed the plans for the proposed special use permit for an accessory. apartment. The proposed change of use has been approved as per plans bearing the latest revision date of January 8, 1998 and this Department's approval stamp. Based on the information submitted, the above mentioned addition is approved with the following conditions: 1...The, total number of bedrooms must, remaii? at f vE, vv'ithout prior , �rr.�vat by this :. . Department. (Main residence contains three bedrooms, accessory apartment contains two bedrooms.) 2. The area of the existing sewage disposal system, and i-ts 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. 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, Jr. Sr. Public Health Sanitarian WH.jP 1 DEPARTMENT OF HEALTH BRUCE R..FOLEY. R.S Acting Public Health Oire:ic.r Division Of Environmental Health Services 4 Geneva Road, Brewster,_ New York 10509 (914) 278 -6130 PROPOSED ADDITION APPLICATION _ (RESIDENTIAL ONLY } ,I !� STREET : � (O FkV MT_ P 1QU T041N GC0— TX MAP # `� NAME:��I�C A'1� PHONE ,5_ NO PCHD PERMIT #O MAILING ADDRESS Description of,Addition ��` �`�x�._ AG Number of existing bedrooms Proposed number of bedrooms from Certificate of Occupancy or -'-'e- Certification from Building Inspector ��'�'� ►.� � yr Any addition which is considered a bedroom requires formal approval of plans 4,55 --c (Construction Permit) prepared by a Professional Engineer or Registered Architect •iL�,7;­ .in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to PUTNAM COUNTY HEALTH DEPARTMENT, 4 GENEVA ROAD, BREWSTER, NY 10509, Phone 278 -6130 with the following information. 1 . Cerif ced .Check for $100.013: ......._. _: __ _ . _,., j 2. Sketch of existing floor plan (all living area including basement, if any) Non- professional drawing is acceptable. 3. Sketch of proposed floor plan. Non professional drawing is acceptable 'A SeTS 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. Include all wells and septic systems within 200 feet of property line. Any questions please contact this office. 5. Copy of Certificate of Occupancy from Town or Certification from Building Department of legal bedroom count of dwelling. OFFICE USE Comments and /or conditions application August 1995 July 1996 (Revised) e. 77 I Si .._._...._.___- ._. -__- __.__..._._._ a t l t 1 . Y _ J ' �' ' �-� •,� .ALL: � � �,- -.. - _..._. - -- - ------ -- -- t7 ----------- i. il e. A5 ............... PUTNAM COUN'T'Y HEALTH DEPAF.gMM4r � DIVISION OF ENVIRONMENTAL HEALTH SERVICES' 1 225 -0310 PROPOSAL FOR SE4Z,(7, DIS POSAL: S)'STE A R PA.11P �i XtM' S NAME /,- ti iITE LOCATION r L ; 4AILING ADDRESS L: ?ERSON INTERVIEWED )ATE ?ROPOSED INSTALLER Jt Name & Relationship (i.e, own i : ' f i• `, �,.. „�\ i.` _( / .� is PHONE PCHD Complaint # er,tenant, etc.) TYPE FACILITY PHONE ?roposal (include sketch locating all adjacent wells): )OTE: Repair must be in same location and of same type as original sewage disposal system. Afferent location may require submittal of proposal from ]licensed professional engineer or .egistered architect.,. 'roposal approved ' Proposal Disapproved Inspector's Signature & Title Date 'roposal 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 canponents 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 drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performBd in accordance with the above proposal and conditions.. as owner, or reported..agent of owner agree to the above conditions. { IGNATURE - TITLE DATE (1 IFS: WAte (PCBD) j YeUcw M-An BI); (.AFplfrerrt Pink ) 1 I _ -, ..... � Fax Covar - heet- TO: 1 EXTENSION: PHONS #s 7 FAX #: COMPANY: AATEs, V ✓ FAX #: MESSAGE: J�� aka ip 'yo DEPARTMENT Of HEALTH Division Oi Envi; onmental Health Services Geneva load, Brewster, New York 10509 (914) 178 -6930 Putnam County Dept. of Health a Oeaeva Road B rev, ster,NY 10501 BRUCE I Acting PubI c Re: Al [ ( 2� 9,(,! es 1 P., $ uvujo, Residence: Tax Map 1owmm tt_ Gentlemen'. ~ ^° r �" '" '`AccorcTtng 'to recoias n "Zai "ntai�ed b} ihe.;SN n, t ie above noted dwelling K- IS IS NOT X in c p ance %rich To code and the total number of bedrooms on record is�yc. wn This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: OTHIERy ;itt .sprc' +.w •i %o.i . i°�i cor f t Building Insp or i c+mr Tie