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HomeMy WebLinkAbout4511DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.19 -1 -45 BOX 34 04511 - 166 : � '' 61 A. L 11 A - 04511 b PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF- ENVIRONMENTAL HEALTH. SERVICES:. ;...: CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at Af - / / /'a j d d Town or Village /u /.12 a.-n Subdivision name -- Subd. Lot # Tax Map's Block Lot II$' Date Subdivision Approved Owner /Applicant Name y 1`%i h: a,*-" Mailing Address /� I%, /� 7u�� �,I Amount of Fee Enclosed ` /o d Renewal Revision Date of Previous Approval A,/Pm 4rs��`lc N 4}G. Building Type %'�j.'�G„ �c Lot Area 46� No. of Bedrooms Fill Section Only Depth to consist of / O ° V 04 . Other Requirements: To be constructed by Zip 1�'6'79 Ad j / Design Flow GPD Zoe Volume gallon septic tank and Address Water Supply: Public Supply From Address on k" - Private Supply Drilled by �' S � S Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. OF Nr Signed: d' `'"� ��vf cis yo E. R.A. Date o ci Address y _ License # , APPROVED FOR CONSTRUCTIO plev es two years from the date issued unless construction of the sewage treatment system has been complet y the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Pu Director. Any revision or alteration of the approved plan requires a new permit. Approvts arge of domestic sanitary sewage only. By: Title: j�i� Date: White copy - HD File; Yellow copy. Building Inspector; Pink copy - Owner; Orange copy - Desi rof sional '` Form CP -97 G T 1 )PUTNAM COUNTY DEPARTMENT OF HEALTH I' IS ON OF ENVIRONMER.N ,TAL HEA .jTH SERVI.CES , -. LETTER OF AUTHORIZATION RE: Property of ��. 4, Located at JZ. MIL4_ PO ,V,3 P O , t%& � A VSVC�ec- / X5- 71 'Wil 9 41-151, PV Tom# _ Flock I Lot Sir- Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize d �i_o� �< VA ✓/ a duty licensed Professional Engineer -or Registered Architect to apply for the required wastewater treatment and /or water supply peiinit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and /or water supply systems in conformity with the provisions of Article 145 and /oz 14.7 of the Education.L- aw, the Public Health.. Ow' and the Pdth ni CoLillfy Sanitary Code. r Ver y truly yours, Countersigned: Signed: P.E., ., # Z ti �'�1S Owner fl ropeny) Mailing Address Mailing Address: 2 ►i_L_ c)ivo ZM,' State % Zip �j ✓'. Telephone: ID State Zip 1017 Telephone: Fonn LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 9-�,.ff4 Address /7 Located at (Street) M Tax ap '1�Blokk Lot (indicate nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA T)nfi- of Pr,--enn Lincy :2,d, T)Ptp nf'PPron1nflr%n Tp.ct /v 01eN R' ' ... .. -T- Ame . .... st op.. . ... .... Time e in.) Depth to Water'' oun From Gr d Surface (Inche Start St a e V Water e 'L vel Drop In Inches ered. q Rate _3 3 2 3 -,7 v3 -3 4 5 2 3 4 5 2 3 4 5 VOTES: •1. Tests to he renenti-dnt zAmr. rip.nth nnfl1.qnnrr)y;mstn1y ennal—ner—nolation rates are obtained at each A 1 11 1 . percolation test hole. (i.e. s I min for 1-30 min/inch, g 2 min for 31-60 min/inch) All data to be submitted for review, 2. Depth measurements to be made from top of hole. Form DD-97 b TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. %} HOLE NO. HOLE NO. G.L. zzlzz;, % 0.5' 1.0' an 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' " 8.0' 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered Alej Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Professional Name: u I I Address: Z g Z Z '��,� v7, e- v-e- Signature: Design Professional's Seal pF NEW\ /ytiP �PpNClS s �9� G y a PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES %* PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR 4,c' pQ`� OFFICIAL USE ONLY SITE LOCATION Val TM# OWNER'S NAME --,frP i PHONE S Z f - 7 75 MAILING ADDRESS r Z PERSON INTERVIEWED PCHD Complaint # ame & Relationship i.e., owner, tenant, etc. DATE © TYPE FACILITY PROPOSED STAL ER ,K�. j ' lG/ , P-IONE 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 proposal from licensed professional engineer or registered architect. I; gs -6trer -or-reported'agent 6f �,jwrier agr-ee` to- the SIGNATURE ZT ! j �7 TITLE DATE 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 comers). 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 �. 2- Inspector's Signature & Title DA COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC-RP 99ML PROPOSM 500 6ALLON SEPTIC TANK PRAdmc-4:- LEACH FIEL * I EX15TINC7 MELL (3 1631-an To DHELLINe ORA PROPOErD ADDITION . IN 000 ANK. T r r"ld 7 Health ,0111,xiarn County 1) �)rlcl M-M - -H. ,Y. v me , i r -:.. a 4! -d -S F-!! -//,/o f� of En' ircm nto; � as noted for ct I th-3 A.0 Rnr ✓ ate BRUCE R FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845)279-6130 Fax(845)278-7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278-6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 ADDITION APPLICATION (RESIDENTIAL ONLY STREET f o1 .� l L 1�0 1� 12 —TOWN-?1;D1 00, VOWVrX MAPS '�'C� • I 1 w '� S �^ W4S S�� 7� — NA1ME J E {- f- M I L Pr A PHONE ?C PCHD# -0 MAILING ADDRESS S'4 M 6- DESCRIPTION OF ADDITION 1• ND 0a P- ,!; i, A i NC ?Doi,, .S-4U NN + 76-14A-ftm NUMBER OF EMSTING? 3EDROOMS 3 PROPOSED # OF.BEDROOMS . " "P4 C 3 (FROM CERT. OF.000UPAIY OR CERTIFICATION FROM BUILDING INSPECTOR) *Any addition which is considered a bedroom :requires formal approval of plans (Construction Permit) prepared by a.Pr(o�wfeyssional yEngineer or Registered A_ rchitect,in accordance.yq applicable sections -r.... .`1 `'PuLLlaln .C�llulty ►7 G1111t.CV.�1G.�:... x. ..aU.:tV . W. w ;,r. ... ,.r s •.yrsr..,..y..�.•..v ..+w w..w— '.�....�.. .., x ..� _.� ..w Please submit this form and the following to Putnam County Health Dept., 4 Geneva Road, Brewster, NY 10509, Phone 278 -6130. 1. Certified check or money order for $100.00.. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) *Non- professional sketches are acceptable. 3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #) *Non-professional sketches are acceptable. 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. S. Copy of Cert. Of Occupancy _ from Town or Certification from Building Dept. with legal bedroom count of dwelling- OFFICE USE Comments Feb98 BFhouseguidelines Q � 1 EXISTING WELL. 0 163' -O." TO ` . E�X)$TIN(5 DHELLIN6 cRA. . PROPOSED` / 500 GALLON % FROPOSED `- EPTIG Tr4NK r�` / V / AMI TION PROPOSED. /� � � ptcX► .. ARAINAGE ' LEACH FIELD / w IN 1000 GA ON SE IC ANK . . Wdk EXISTING �► DRAINAC -E LEACH I`IELD ' o��m f•S' os1 0.8' 6 102- / Putn:arn Cots nty `�rri io{ n .�f Env i� i� k� rice �/ 4i as noted.�o. �+.}�i �� t. aoC�" :"ttUr® Title prjTNAM COUNTY HEALTH DEPARTMENT n. � ;10p;,OF ENV 4NNlENTAL�H��L.TH SERVICES w. 4 SEWAGE OF USE.ONLY : SITE LOCATION :.. 1 � �6�a�L✓ �WIVER'S NANJ`' 2 MAILING ADDRESS 7Z n r l PERSON INTERVIEWED DATE PROPOSED ADDRESS �.� PHONE 5-2- 0 7-7-70 PCHD Complaint # e., owner, tenant, etc. TYPE FACILITY 1 i ' • � z •. i i S "iS� . r 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 proposal from licensed professional engineer or registered architect. I, as owner, or reported agent of owner agree to the conditions stated on this form. SIGNATURE 4T � TITLE DATE Proposal approved with the folio d a� itions: 1. Procurement of any Town i 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 comers). 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 DA COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP. 99ML