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03875
PUTNAM COUNTY HEALTH DEPARTMENT 0���
DIVISION OF ENVIRONMENTAL HEALTH SERVICES �� (-
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YES NO Internal Use Only
❑ 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 0 nd ❑ Joint Review
SITE LOCATION d4 v_-rPL o m7- TM # 3 < < (3L-3—`7a
OWNER'S NAME A<A Rrz P( Z (4L6 J tq Mtq M PHONE #
MAILING ADDRESS
APPLICANT 40 W14 -rkb SEA(; � i
Name & Relationship (i.e., owner, tenant ctor)
Ud
DATE l d FACILITY TYPE (47_S PCHD COMPLAINT #
/+ cpc( rr7� - 38Y7 c etc
PROPOSED INSTALLER w(� r-t66 rZ 2T PHONE # 6 0? 5_1
a'K 6 SC-c4• wv4 F4 L-17- R
ADDRESS !Rv'rNl$K U �A.LLf�YI �' REGISTRATION /LICENSE # I _
6 d
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architec t-
14 i
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0 W e— C S h c11,A, _
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C.•- a s 3 s bu, (XT 1-�- �c�w
I 3 4= etd$ N`t 1-0 i,4 repte -c , i./Jr
I, as owner, or reported agent of owner agree to the conditions stated on this form Jrr_. n-r
SIGNATL TITLE DATE
Pro osal a tl with the followin 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,
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number.
3. System repair to be performed in ordance with the
above proposal and conditi ns
Propos I Approv Proposal Denied
ignaturQ & -Tttl _ : ��� �. ,.m _ :Date-,- _ :.� ,/�.: _ __ ._ - ...
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
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acrcriowieage receipt of this report SICNA�TURE
TAY
SAY
Rev. t MAT 7
r
f
a
x
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
July 2, 2007
Howard Gragert
296 Oscawana Lake Road
Putnam Valley, NY 10579
Pie u*
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
Re: SSTS Repair — Ingerman .
35 Dartmouth Road
(T) Putnam Valley, TM # 83.12 -3 -72
This Department conducted a site inspection for the above referenced project on June 28,, 2007.
It was observed that the septic tank repair approved on June 27, 2007 was already completed and
backfilled without any apparent. attempt to notify this Department before backfilling. This
Department requests that the septic tank and any new lines installed be exposed for inspection by
July 6, 2007. If the tank and lines are not exposed by July 6, 2007, a violation notice will be
issued followed by a hearing notice.
Please contact this Department if any questions arise.
JSP:kly
Sincerely,
/ Joseph S. Paravati, Jr.
-.f Assistant Public Health Engineer
Envii oeimeiiral rtieAth (845) 278 -6130 "Fax (845) 218 -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
MEMORY TRANSMISSION REPORT
TIME JUL -02 -2007 02:55PM
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 051
DATE JUL -02 02:54PM
TO 918455262595
DOCUMENT PAGES 001
START TIME JUL -02 02:54PM
END TIME JUL -02 02:55PM
SENT PAGES 001
STATUS OK
FILE NUMBER 051 * ** SUCCESSFUL TX NOT ICE * **
County Er <ca.rivr
M4171 BN.&RC. RN, MSN �E+ MCDO ERT MORQtWS. PlE
Rssoclata Commissioner oj'Haalth Olrecror oj'Gm+lrorrmuttal H¢olth
IOEPARTME"-r OF HEALTH
1 Geneva Road. Brewster. New Yor(: 10509
July 2. 2007
Howard Gragert
296 Oscawaria Lake Road
Putnam Valley, NY 10579
Rc: SSTS Repair — Ingerman
35 Dartmouth Road
C•7') Putnam Valley, TM # 83.12 -3 -72
boar Mr- Gragert:
T-1xis Dcpartm(ent conducted a Site inspection for the above referenced project on June 28, 2007.
1t was observed that the septic tanl: repair approved on June 27, 2007 was already completed and
backfillcd without any apparent atterrapt to notify this' Department before ban1 filling_ This
Department requests that the septic tank and any now lines itzstalled be exposed for inspection by
July 6, 2007_ If the tank and lines arc not exposed by July 6, 2007, a violation notice will -be
issued followed by a hearing notice.
Please contact this Department if any questions arise_
Sincerely,
Joseph S. Paravati. Jr.
Assistant Public 14ealth Engineer
JSP :kly
Jr-1 —tal ti aalti. (845) 278 -6130 Fax (843) 278 -7921
Water Supply Saetlon (845) 225 -5186 Fax (845) 225 -5418
N""Ing Servi —S (845) 278 -6558 Fax (845) 278 -6026 W!C (845).279-6678
N arsi..g Home Cara Fax (845) 278 -6085
Early lntervantlon/Preschoo3 (845) 278 -6014 Fax(845)278 -6648
MEMORY TRANSMISSION REPORT
TIME JUN -27 -2007 08:02AM
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 916
DATE JUN -27 08:00AM
TO 95262595
DOCUMENT PAGES 002
START TIME JUN -27 08:80AM
END TIME JUN -27 08:02AM
SENT PAGES 002
STATUS OK
FILE NUMBER 916 * ** SUCCESSFUL TX NOT ICE * **
AM LER. MD. MS. ROBERT J_ °-
CorntnsssIVIII- a. muk,rh yr Costnty �aw"rt"e
LORETTA MOLIIVARa. RN. MSI�t <<'` ROBERT MORR[S. PE
AssocloJB Commiss /over ofHaalrh Oir¢ctor ofEtavlionmonrw/ H¢olth
L7EPAFRTMENT 4F HEALTH
1 Geneva Road. Brewster. New York 10509
Ton NOWARp CiF2AGERT T'''°"f9 PCOO H -EHS -JOE PARAVATI
Faxa 278 -7321 2 (including cover)
Phonen 278 -6130 laatr: 6/27107
Ras ING7^RMAN SEPTIC =
O a ftia t O For Ravlew O Please Commcat O Pla3aaco Ropy Q Please_ RooYO1a
in the Gwent of trsnnsmfsslon/receptfion di.8➢caalGes. plemse contact the Environmental IIoatth
(E73S) -&Mae at (843) 278 -6130. Tlaanlc you.
)Please sign ar[a3 re-turn, thank you!
The Irlrorm -lion cor+twlra¢d i- this f- csimr/¢ is co denttcrl and is int¢nd¢d only for the e 0,1,12¢ taam¢d addr¢ssccc If the
_e_ of this mrssoge is nut rh¢ taam¢d wddrQ s¢e or th s person responsible fu ac liver, It to th¢ __f addrrxscB. Ynra Gv�
hereby t fjlierd thcar arty :rse of thLr facslmi /c or its copying 4 rrler/y prohlbltcd. {y jwu
hav¢ r¢celv¢d this _rso Zmilo in error, ple imttt¢die 4aly not&5, the Pahl Coamty Dep-rtmcnt of lyetwlrh by L¢phono at
275 -6130 wnd mall the crt rh¢ -bout wddr4•.ss. W. will ro/mb —Yuw t ,pleol n and post -ge
axp¢nswjnr dot gsu. T /awsakyou.
avrvw_patatatracortnp,ny_com
Envfron mentAl HcaiCh (845).278 -6130 Fox (845) 278 -7921
Water Supply Seerlon (845) 225 -5186 Fax (845) 225 -5418
Nursing Se—laos (845) 278 -6558 F— (845) 278 -6026 WIC (845) 278-6678
Nursing Home Caro Fax (94S) 278 -6085
Early Inter ntion/Pre hoot (845) 278 -6014 P (845) 278-6648
A�Orq (Q- pf L k 4- 7-,( o �
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JUMT-It00T 01:01Att FROHNVIRON49NTAL WEALTH 845270T011 T -810 P- 600002 F -018
Q DIVISION OF ENVIRONMENTAL HEALTH SERVICES
qolv wdwww<er a 1 &vatCd Oilsoa►ler
InterrAd Na only�
❑ Flow Pamtt Issued to last a Yaffe v Not in WeWshed '
❑ L] Repair wean eoyd's Camara. W. branch Oman F0% MU. Q o wepated ��
Q ❑ Repair wb1n 700 fi. of 0 wa reawwv or CGO wm sd L1 joint Rwiew
SITE LOCATION t%AT TM # 85. (X- ,3 ^ p7a
OWNBRV NAME �C1� RIi! lt{ ; mat Q m_ PKW77 P i0NE#ftr. � J Z" ( 4
MAILINS ADDR68S V-J -, !� `L4 ` I ��2 .�
APPLICANT 0 cMl4Ra rwcAr _ .....�
Name s Aala donir►►p (I.e., Ownw, ten■rsta,dpovJJdR+1
DATE FACILI`rY TYPE Pam OOMPLAINT
PROPOSED IIYSZ'AL c R W (%. " rL A ' ? s � �M "
#4
ADDRESS H ' REGISTRATION ILJCEN8t: # !:n I
r 0 S'-7')
feet of repair and the lamtlan Of a>Idsgno and proposed trenches)
NOTS: Repair must be In aeme lonton and of soma typa ee w1gl l sewage did;iwal system.
Different loosdcn and propoaod pup systMms WE require suibmtttal of proposal from keneed praAwslonail
anginesr or r+eglownetd arahloaL 1
+vR EPtxt: �J4 - F i� ba icp +Mad �ar+�� r �t�/1 6r..wd'►+.: i►,i
I. as ownsr, or repamw ags?040vNfvJ0&"AM r agree 10 to mdktorla stated an We form pi's. A01-h-hj Af b9AM i0pa PAilli
SIONATU + DATE
.f 7
I. Procurement of any Town Pen+ , if apppca4ta.
2, aubmiselan area built repair eketatt In dupAeats showlne:
a, pwnar's name •
b. arts alreet Nwe, Town and fax Map numher
c. Laoatlan of Inarallad campmPta tied to two Itzed poeMa
d, byebm deMAPOw (04., 12M gel. Canorats eaptle tank, ate.)
o. Inafari06ta' name and ph;�2 3. Syetsm rrpsir to be pe dOmronce with the
above pnmposal and wMill
Fmrw Appoved ^--7 Prapo�=l DeRled
PA Ins R is 1pneture 8 tie
CPILrS: White (POND). Yellow (Town Big Pink (Installer), Orange (AppNcant)
PO4tP 99ML
Rev. 6/015
JUN- IF-200T 011:01AM F11011- ENVIROMINTAL N @Alfa 846171 Il %116 P1001A02 P -016
SKULiTA ANLUL M ll,K64 FAAP
Comertlsloner crk►ealth
LOitETTA MOLINARI. AN. M6N
Amoc 1014 COmmiralomr of Xealth
DEPARTMENT OF HEALTH
1 ftee a hood, Brewster, New Yoelt 1 0509
NOflW & BONDi
Como Ewwwj--
ROBERT MORRIS, n
'Omfm PCWH -EH& l0E PARAVATI
pag"
baw MCI
Q urleo C3 for ftW# w ® Ple®an @Gmment Ci Flemm MPIV .. __..R islesse R"yolet
In the event orlmi m don d0culdea, p1ci coafto the Environmaim tW Beam
(EHS) 0>111m at (843) 278.6130, Tbask you,
1,105 #Ormadolr ec"atltrtd in thy facloWil to coqrt*mrf f and is Intended om& fir the to of Me wmod adabww . !f dw
r r q/ i tY musap le gat the Hamad a0waa+s or do panels rapooffile to dolh ar It to the mtntmd &&wvmg yov ana
hdrby MI#2rad drat ml y gull of tbtt f mlltmlla or !rd contents, irse a tnl� dhmmtnation or &�*k C u sirlcrbo p *Affilmd 41 yw
fsan+e reVhW thdr fketmllo in actor, plaasaa lsnnoijs'rrely.►at tlrc Pubtntatn Cotarq+ Doparlenarrl 1"Mss♦stltA by nvlapha of
(W) 278.81.10 anti maU she arolnal,teslmlla to w at the above addrrss. We -4111 rots+ ww >ww 10k* mm and pact w
aacpet Ai- doing so. 7Yta nk yorr.
iv�aq per+ �lr.
Enrkewa®ioul 1l0094b (043) 278.8130 ;AK(843)278-7921
Water Supply Wien (80) 225 -5186 rax (843) 222 -5418
Noraln8 3eralsyas (8491218-[3936 Fax (845) 77$.6026 WIC (843).279.4676
Nurdas Mamma Care Fm (845) 278 --6085
1rtjj ifiitafi6S`el;�tiF1'�aas� �5)1SS� i .F�tY (y g ?:: *ge . 8.,
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Fax
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
To: H
HOWARD GRAGERT F
From: P
PCDOH -EHS -JOE PARAVATI
Fax: 2
278 -7321 P
Pages: 2
2 (including cover)
Phone: 2
278 -6130 D
Date: 6
6/27/07
INGER%1?;A J=SEPT1G—
In the event of transmission/reception difficulties, please contact the Environmental Health
(EHS) office at (845) 278 -6130. Thank you.
Please sign and return, thank you!
The information contained in this facsimile is confidential and is intended only for the use of the named addressee. If the
reader of this message is not the named addressee or the person responsible to deliver it to the named addressee, you are
hereby notified that any use of this facsimile or its contents, including dissemination or copying is strictly prohibited If you
have received this facsimile in error, please immediately notify the Putnam County Department of Health by telephone at
(845) 278 -6130 and mail the original facsimile to us at the above address. We will reimburse your telephone andpostage
expense for doing so. Thank you.
www.putnamcountyny.com
Environmental'He"alth ($45) 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
MEMORY TRANSMISSION REPORT
TIME JUN -27 -2007 07:55AM
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 914
DATE JUN -27 07:51AM
TO 95262595
DOCUMENT PAGES 002
START TIME JUN -27 07:51AM
END TIME JUN -27 07:55AM
SENT PAGES 000
STATUS NG BO
FILE NUMBER 914 * ** TX FA 1 LURE NOT I CE **
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Commission¢r of N¢o /th # +f .. .. -. _ -:• : .." ''Loa.:rry- .`- _xsCa+aSvc -': .. . - _._... .." __ ".. -
II..bRE'Y'TA MOa- 1NARa. RN. MSN �^ O R®Bai.RT M�RRiS. PE
ArsOCivt¢ Gomm /ssio »¢r ofHcallh D /rector oj'Errvfronmantal H¢olth
flEF'ARTAAENT OF HEALTf -1
1 Geneva Road, Brewster. New Ycrlc 10509
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Cn the ¢vent of trsnsnvtsslodreceptloa, cIlifficulale�, pleaa_4t, contact Ylae lEnvironanenaal %3eatltl><
�EH.R) office at �84s� 278 -6130_ Thtanlc yoga.
:PIlcase sagas and retlaa n, tiaaua4c y®aat
-7'he [rrfturmarto.: contained in rhtc focsimtle is co�dsnr[o/ and Lr /nreird¢d only for the ace fthe named add essee. /fthc
redder oy'this is not the named addressee or the person responstbia to dell F! to 0— named odtlr¢.r_sces, you errs
hereb3> nolf¢d that y use -ef rhLsfaertr»+Ic or ice contents. lneludin�g dissemfnarion or copying Lr srrlerly prohibited
have rvcciv¢d this facsi3ntie In ¢� or. pta•LCre /mmodlotely notify rho 1°ttrnam County Department of N¢alrh by telephone at
(b•4SJ 27ia -6/30 a »d mail thm orlf;i »o /•facctmile to u• at tha above addre -rs. We will rarimiiursa your tchspfto »¢ and punrago
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Envlro..Maetal Heoltl. (645) 278 -6130 Fex (845) 275 -7921
Water Supply Sactlon (845) 225 -5186 Fax (84.5):225-541 S
Nursios Services (845) 278 -6558 Fac (845) 278 -6026 W1G (845) 278 -6678
N ors:ng Home Care F— (845) 278 -6085
Errly ln[ervention/Pr•aschool (845) 27R -6014 F— (845) 278 -6648
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