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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES g3,��-'p? -.��
PROPOSAL FOR SEWAGE TREATMENT SYSTEM, REPAIR
YES Internal Use Only PER I'T -1i 77 " t-)
❑ Repair Permit issued in' last 5 years . VDOOI��ted
Watershed Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION �9 (�. �P.iS ► I TOWN '' Tv K"'' �% TM a
OWNER'S NAME l ✓l C5,1 cAA19-e --',P PHONE
MAILING ADDRESS 3cas- Lvr lg�t r+ (� -ce. 1 G•,
APPLICANT
Name & Relationship p.e., owner, tenant, nhractor)
DATE S D1 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER `o Gp! �✓ Y I��cJ�1 Q /n/G PHONE # e yS 6G1 0-)-Z1'"
ADDRESS 3 t���. Lnl Lam/ { f . REGISTRATION /LICENSE # Pe, .7037- /f,& 0.3
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 profession depending on the
nature and eidt t of th repair.
/,V� Fl /1%C k) 'rep T C
O `i• iN t' %/7 rctl� r s • C�G�z y 5/
I, as owner,agre7the
d' " stet n thi , fomcY SIGNATURE TITLE �%� f� DATE
I; the se' trinstaller, agree -t com ly'with a conditions of this permit fo( the septic system repair.
SIGNATURE TITLE 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 feed 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 ft design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be ba77until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Q Proposal Denied ❑
In pector's Signature & Title ¢ r ratio Date
Repair oroaosal is in comaliance with applicable odes Yes No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07;;
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PUTNAM"UOUNTY HEALTH'bLPARTM'ENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE
All information below must be fully completed prior to any scheduling
SITE LOCATION 0- TOWN UA- P4TM #
OWNER'S'NAME 6,9 PHONE #
MAILING ADDRESS Q0 !9'- 1, A-
PROPOSED CONTRACTOR /INSTALLER PHONE # ,-3
ADDRESS % -REGISTRATION /LICENSE# f0ff7f9 1//Q-L3
Reason for exploration:
failure to surface 0 back-up in house K—find limits of system for repair 0 other (explain below)
FOR COUNTY USE ONLY A41e?e j-c o4 iP r
3 -3&A-,o w5 /,ev o&, a:,,L 7,-w
-Ir 40 1�4 '5411i-Oeev
Sig
Appointment Date:
kly: excel: septic
X41
Time.:
Dfate P
MEMORY TRANSMISSION REPORT
Tii+' �t =ilo' °20=ri G927;tni - - ;
TEL NUMBER 8452787921
NAK ENVIRONMENTAL HEALTH
FILE NUMBER
DATE
TO
DOCUMENT PAGES
START TIME
END TIME
SENT PAGES
STATUS
FILE NUMBER 125
125
SEP -06 09:25AM
85280781
001
SEP -06 09:26AM
SEP -06 09:26AM
001
OK
* ** SUCCESSFUL TX NOT ICE * **
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
3.l05" a -.33
L^7 / LuI Ropalr Parrnlc /sates M last S ya9rs U In waiaranao
Repair —IMIn anyd's Carww". W. t9rar�eh rF C/Otnn Fails Ras - ®Ie9ataC1
O Fl. air within 200 TL ar a wataroo .tss w OECr...aooaa wauarw O ,Joint Review
SITE LOCATION
OWNER'S NAME
MAILING AOORESS
APPLICANT
409
a..-, . 6'> A" /
PHONE a JP
g' /03- f � / Y Y • ��^ FACILrTY TYPE �'i� ��°"` PCHC COMPLAINT J!
GATE �_ •
-- - - r+�r,�r�rns�c> cw_s•s.aLL�iz- .. �'mG� / 6 ✓� � /�.••.,�.•..•,�� .��PHan+�eai s°Y.�66/ O� -�t--
• ADDRE88 '�- �'�+.0 � L.✓�Co9'>�_:'� -ict L' -!%9s° FtEGi'.3':i-wTivN:Li: iERS`.'t�di p�3�:,.r'-- � J's�:� -
_ Proposal (Inaluda a separate altetclt locating ttte itousa. property iinao. all ad)aaenit wells wMilrt 200
iqe oT repair and One lacagorr of eziating and proper SYStam)
NOTE: The r3apertment may require submittal of proposal from licensed professional depending on the
nature and extent of tno repair.
1. as owner.agre , to the sta this form �e
SIGNATURE �� TITL.E (f)WR eJ'�. DATE
(owner
1. the sepV Iler. ag ccrll ly with /Aha - conditions of this permit for the septic system repair
SIGNATURE �i� %� TITLE,�6 ��a ✓-� __ QATE �`�� / 9
pnamw""ll
�•.+ mil a��..sd witlh y.a follow = conditions:
1 . Pro�anarrlarrt of an, Town Pe.rh. H .,-Cmbia.
2. Submission W as built repair aketoh by the septic system installer within 00 Clays of the repair, in dupftoata shotMr a:
a. Owner's narta. She Street Name. Town end Tax Map Harbor
b. LoCatlon W Installed components fled to two 11bead point=
c. Systar description (e_g.. 1260 gal. Concrete eeptio tank. atc-)
d. InatallsmW name and phone number
3. System repair to be performed in accordance vAM the above proposal and coroOMons
4. Tha proposal SST8 repair IS consldared a bast fit design and meta Is no gunruntae W the tlurntion at which the
aorX90tad SS-1`3 rapair will function -
6. "a, comploted work Is to be b kctcHltqj*-onttl authorlration to d0 so has bean obtained from the Otepartrnart.
Approved
Proposal Denied
a • �
COPIES: PCHO:Owner. Installer
PG-RP 99ML Rev. 2/07
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PuTNAm COUNTY DEPARTMENT OF HEA13H
HOUSE PLANS APPROVED FOR
BEDROOM COUNT ONLY.
BEDROOMS
I-HS 71710C.
(below AlIllovi)
Signature & Me Dam
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SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
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LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
September 7, 2006
Paul Goldenberg
Jan Calman
305 Lake Drive
Lake Peekskill, New York 10537
Re:
Dear Mr. Goldenberg & Ms. Calman:
ROBERT J. BONDIt..
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
Addition Approval — Goldenberg & Calman
No Increase in Number of Bedrooms
305 Lake Drive, (T)PV, TM# 83.65 -2 -33
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 September 7, 2006. - The addition is approved with the
following conditions:
The total number of bedrooms must remain at three without prior approval by this
Department.
2. The area of the existing sewage disposal system, .and its expansion area,.must be
_..' - ... .. � .lfidinCdliied. ._...... ._ _..n,. .. ...... _:_ _. = - -.._ ,.. .v .... .,......_ ..._.......... " � .. _.._... _ : ...._..._ . _ ,
3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush
toilets, restrictors for shower heads and faucets; etc.
4. The approval is for the proposed changes only. This approval does not validate any
construction shown as existing that has not obtained proper approvals.
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,
Mike Luke
Public Health Sanitarian
ML:cj
cc: B.I. (T)Putnam Valley Environmental Health (845) 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 InterventioniPreschool (845) 278 -6014 Fax (845) 278 -6648
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SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
� ' -G V i�7d'i'Y"t�►'Si'l V�i'.li \l�1li� RI�1� ivl�Sl i� . • • u � � �'`•~ • .. ,
ROBERT I BONDI
County Executive
Associate Commissioner of Health
DEPARTMENT 'OF HEALT i S
Geneva Road, Brewster, New York 10509
ADDITION APPLICATION
STREET 3o5 LA kC .D2+ vE
W IV A-M 1._
TOWN PuT'WAAA VALLC . TAX MAP# 03,'�S
NAME 4ol. >GtJ06(24 I CALMAO PHONE � 4 528 44pj-3 PCHD# -- O
MAILING
ADDRESS 565 LQjegr D62W15, L'A1 -6 PCE(05(e-(LL- 1J -Y- 105"
DESCRIPTION OF
ADDITION Pevv 15x-10 M>r>moN Tv. K(,re—"Go 4 670r(zy
NUMBER OF EXISTING BEDROOMS PROPOSED #. OF BEDROOMS 3
(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., 1 Geneva Rd,
BrewEt r., :NY 10509, Phone: (845) 278- 61.30.
.fl. Certified check or money order for $100.00.
„/2. Sketches of existing floor plan (drawn to scale, all living area including basement)
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 locations 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 Certificate of Occupancy from Town or Certification from Building
Dept. with legal bedroom count of dwelling.
OFFICE USE
COMMENTS
Environmental Health (845) 278 -6I30 Fax (845) 278 -7921
Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
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SKERLITA AMLER, MD, MS, FAAP
, Commissioner of Health
LORETTA MOUNAK RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Town Legal Bedroom Count
ROBERT J. BONDI
County Executive
Re:fiLut-4oL-pc-t3i3Etz414"6AL.m&il (Owner's Name)
Tax Map #: e'5 - & 9- S - '5 3,
Address: -*305 LAW-E D2tvGb (-Aie-g: pCElGSictLty
Town: L%-rtjAA&- VALLC--Y, Kj'y
Year Built: 1'7) 5 0
According- to records maintained by the Town, the above noted dwelling,
i�'nce W.
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is not in compliance with Town Code.
The Legal Bedroom Count is: 3
This information has been obtained from:
Certificate of Occupancy:
Other. "ULDG- --'bEP4-, 'TILE- 3) _PL.AQS
-61 1114
Building Inspector Date
Environmental Healtb (845) 278-6130 Fax (845) 278-7921
'210 4442 Far Mil 77R-6q 26 WIC (845) 278-6678
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PUTNAM COUNTY DEPARTMENT OF HiEOM
HAUSE PLANS APPROVED FOR
BEDROOM COUNT ONLY: — - – --
3 BEDROOMS E x I. S. T. I N 4 . D E G le-
91fnabn Tift Date -
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