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HomeMy WebLinkAbout4582DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.06 -1 -16 BOX 34 T 04582 BRUCE R. FOLEY _ ,Public... Health, _ LCZRF,_A EJLT'h'A.1 '.:itris',•= iVl:�:i3'� `"c ;s:;. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New, York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914). 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 Steindler 23 Dring Ln. Putnam Valley, NY 10579 Dear Mr. Steinler: September 29, 1999 Re: Addition- Steindler, Dring Ln. No Increases in Number of Bedrooms (T) Putnam Valley TM# 85.06 -1 -16 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 site inspection on 9/28/99, and plans bearing the approval stamp from this Department dated 9/29/99 .The addition is approved with the following conditions: 1 2. 3. low The total number of bedrooms must remain at four without prior approval by this Department. The area of the existing sewage disposal system, and its .expansion area; must.be_ -z' marztaiuedY All new plumbing fixtures must be updated with water saving devices, i.e., new 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. V ruly yours, Michael Luke ML:kg Public Health Technician cc:BI A. BRUCE RFOLEY •., a .::i.::,�<c":" �-- -���r��" �� dL�„�- ..:y.n.;.. i* ":y',i.: �.�n:- _..mow,. ,. Steindler LORETTA MOLINARI R . M.S.N. �am:�. ro =:� :r �sarlate• �� ?a'�he�]Ye�lih����irei;tor`'�° "�':;'�"- Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New. York 10509 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 23 Dring Ln. Putnam Valley, NY 10579 Dear Mr. Steinler: September 29, 1999 Re: Addition- Steindler, Dring Ln. . No Increases in Number of Bedrooms (T) Putnam Valley TM# 85.06 -1 -16 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 29 /The addition is approved with the following conditions: The total number of bedrooms must remain at four without prior approval by this Department. 2. The area of the existing sewage disp al my os system, and its expanslonarea„ t.be 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrietors 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, . Michael Luke ML:kg Public Health Technician cc: BI DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 TeL (914) 278-6130 Fax (914) 278-7921 PROPOSED ADDITION APPLICATION (RESIDENTIAL ONLY) BRUCE R. FOLEY . :rte STREET D LOWE TOWNTV`1- Vk MAP # NAME C El V� Q---2 PHONE 0' ' CHD # O 1 J MAILING ADDRESS _ ro w 4- � DESCRIPTION OF ADDITION NUMBER OF EXISTING BEDROOMS (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) PROPOSED # OF BEDROOMS *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 subnut "this form dnd tli� following to'Putnam County Health Dept., 4 Geneva Rd., Brewster, NY 1009, Phone 278 -6130. �. 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 eCopy 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. . Copy of Cert. of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE Comments Fcb 98 .. ti -: Tr '.. : ir- �•:".%� ":. �- ..':!`+c> �r w..:. •::%� ".'s • :�'- :t•S' C.t:. ., -y ^ n'.+. q'•i.. o . -. BRUCE R. FOLEY. R.S. Acting Public .Health Director 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 Re: Residence Tax Map /d Town -u � t]Rlte Gentlemen: According to records maintained by the ToNNri, the above noted dwelling . .. . -r � �.. -mow _. -. .......- -•.. � ..rs m w_-. -� _ _- - �. : _ � _ c _ ...�... --. - -. ► ..... _.w.. ..ry . sc.. ca.,. _ � -._ c .. , IS NOT in compliance with Town code and the total number of bedrooms on record is 3. This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: C/ OTHER Building Inspector `r e PUTNAM COUNTY DEPARTMENT OF Division of Environmental Health HEALTH CERTIFICATE OF RU Services, N nCONST ` CTION CQAAP�,IAIti!'S'L Carmel Y 1081 r ►.�+irs '.�..� �N ".Z.. pt..- ..,- ..!!- z -avJi. :mss;•'. ��.. �„� Located at ,� c!q << 4 ,� Owner C.±f �.�c /�['i` �` Town or Village , Separate Section (p Sewerage System built by .rig/_ =' J Lot B Block . Consisting of . I <C "C J Job —Gal. Septic Tank Address r�C�/ Other requirements ,q Water Supply. lineal Feet X 3 J do'trKS'K, i s J 4 Pubtfc Supply From width trench v,. Private Supply Drilled BY Address Building Type Has Erosion Control Been Completed? _ No, of Bedrooms_ � Die accordance Permit Issued ( s attached), and in n c a listed serving the above With the Premises were Constructed essential) standards, rules and regulations, plans filed, O y as shown Date !/�'C �� , 7/ �, and the permit issued plans of the completed Work / by the Putnam County (copies of which are Certified by my Department of Health. Address 'On Person oecuPYing premises Served b P.E. :onditions resulting the above available and g from such usage, SYStem(s) shall r Bl h/J the approval of the Approval of the promptly take such License No, ub)eet to modification °f Private water su Separate sewerage action as may be necessary 00 change when PPIy shall become null and void shall become null and Y to secure the �— , in the judgment of void void as correction When a Public water Soon as a Public °f any unsanitary the Commission f ealth, Suppl omes available, Sanitary sewer becomes ate ^ 'yam / /— such revocati / —- mad' f cation or Such approvals are change is necessary, By - t� / / J Title If yield was tested at different depths during drilling, list below FEET 7 GALLONS PER MINUTE DATE OF REPORT WELL D LER (Signs e) /� ! ,a. P jv ,x ' f k t. % � d 1 }t 'S y. 3 CERTIFICATE OF OCCUPANCY t w Certificate of Occupancy No..4.. ...... Application. No.. 7413 ....... ;f Location of Premises .....DX'�,ig.. its .......... ................... .—.1 ...... I I... I el— ........... ... ....... ........ ........ . ........................... of . vlaam..Val ey.... . e................... -- .......... having heretofore filed an application for a building permit pursuant to the Zoning Ordinance, Sanitary a Code and the Laws in effect in the Town of Putnam Valley, Futrn County, New York, having paid the required fee therefor and the undersigned having by persobal inspection ascertained that the applicant has subsequently proceeded with the erection or impt6vement of the proposed struc- ture in compliance with the requirements of the laws as aforementioned and that the said work arc and materials met every requirement of the laws as aforementioned and that the premises have "to now been fully completed and are ready for occupancy pursuant the provisions of law, Now, ,r 4 therefore, this certificate of occupancy is hereby issued under the seal of the Town of Putnam 4 b'.... day of .... ..... ....................... 19. ?.2 Valley this .. MaT Not valid unless signed in ink by a, duly authorized agent TOWN OF }PUTNAM VALLEY,.,-NEW YORK of and under the seal of the Town of Putnam Valley. - By <y 1`. nt " li :S 1, !• t I tr Q , p1 %r••I RCEL NO. B WELL ON ?HIS 'CEL . x 2 Q e 1 � 6 es.o? J�~ ry 4 AD•C I /ll 86 05 •05 / O WELL, o / ^ DRIN Ci ,1 .t " -" 12LV CO L. N _. P, - J z d: TACONIC STATE PARK COAMISS104(N0Wcu -yenrr Cafpenrer t9 .. CcD . SNO"WYN NaR �� ►o*� ON SII8D 1VJ5104V Cn•if _ Fngr»eer3 f�_' .1:.?nd Sgiveyors. • " *� ." �'. ro>.Yfi vij, tfPighfs, JV Y jj • " BLcc�,; L for= PAROEE NO 24 WELL- ON rHAY PA , Rr,� ESE a1 0 At 14 HE 10 1 i ;1 1�i •j . d1 PROF /Lt VERT : 4' Y:: •',- COMS �5' *' c 236E : A9SCRi'< "06E'- S�ACEL� "G i 5 I,C ..:'X ro Brti fZ00 &C5 .0,v. 4c 300 GAL. PER BE'OROaV X 4 BEDROOMS y APPLIED RATE =706 GIS.E =36 TRENCHES - 236 4F 4S 8U /LT, T E. PL.Bli/ OF PROPERTY Fpf A 9ER—..;r :J TE d.Y dJLER. 4 /�1 A ld�9 G©U , -I T Y; WY FI EL ✓S r --• BE 4 " PC J/g7RQTEJ OH.T!' /5E9;1 APPROVED OR EOUAr- sp .rO ✓ iIJ "7lav BCC ay y` B£riY.EN 4 '•,;AS.T •f`?ONP�P£ TO B£ USED HOUSE A TANKj; •�_.. 9U/iDER TO KEEP P10 5C,D 5E71C 4REA 1%AV4 %Z TRAFF /,;: a •;ON,;rAptil/ON DEER /S 4NO r0 AOE4Tr iaA /N•:GEjrOPRE ✓ENTEROSIOI/ SYS=f. -M IS MIS alt wrtR o.MU�IM 4Y4 42 L GnN5 rRU; flOMYO BE DON£ /:V 4CCDRC_ $lifalHlM64gL WI M WYlW DE'SIGN.' 300 GAL. PER BE'OROaV X 4 BEDROOMS y APPLIED RATE =706 GIS.E =36 TRENCHES - 236 4F 4S 8U /LT, T E. PL.Bli/ OF PROPERTY Fpf A 9ER—..;r :J TE d.Y dJLER. 4 /�1 A ld�9 G©U , -I T Y; WY ay y` j LAWE ?J t'a► -M AP.Wo. 6eo JAN 19 6 mr Imp 300 GAL. PER BE'OROaV X 4 BEDROOMS y APPLIED RATE =706 GIS.E =36 TRENCHES - 236 4F 4S 8U /LT, T E. PL.Bli/ OF PROPERTY Fpf A 9ER—..;r :J TE d.Y dJLER. 4 /�1 A ld�9 G©U , -I T Y; WY I EY ?10 ^in 0 a ................. - E OF: H)EALTH NT- C*rlyiel N-- Y -10512 TRU yi -ToW`n--*—r,'vMne 0 Section 419ck Lot Ae Yw n'er, Address&AIA Lot Area 2!!2; r Orris -Total Habitabld Space square Fiwt'A Um W le: Septic Tank lineal feet X width trench ctadgb Address bite -V: 'sup 1 0 -Al A_ R. y MW ddro%3 -M • -FWW0_ COMA ) At" fd ca _7 irr Ono "�Tntp) I V-Se perate ag, tQ, andIp accordance ens of.: the Putna p$truoed shq%yq on the approved a, WR4 the 2ndaro�, Ul" and reguW0 r"r"1 4rtTnl P(Aoolth,".nq to'at pn.co pletion ttioroof a!jCer.tljjc#9; if, ponst(ucilorl Cor sa octqrylqj M I nor. of "Galt, will ��i! popp,W� - hi a- succe"16 _iMW-..WjH Their of 1143 11S.—A "wag® 9f,tyq,O), to .9 the per ears 110M I& 91lowIn the I l.1;01`11114&14 of C-4nstruction -CornPiim!nc@Tof.ttot,*OrioinaI fystorn or any4repa#j rope jWj 4?121, ttaat�tne drliW well described above' 11 will Pe In tied' ­ac�ordanco with tne. si to 'it the T Pq 100-C�W��9_ h!, Entp wtk= we MSTOCNION his-approval . explies one'year.frern tholdato Issued unless CohWu t ;Qox of.1he bulklm has tH u i;4 r a :or OY 08.8mended or M04 Uled When considered necasgry by the Commissionor of"Health. Any, change or 44ter4tion'of construc qwi. r i Approved for spo I of domestic San /or PrIvate ter, tppW only: . . . . . . . . . . . . .ri SOIL TESTS: 1st ,..........min.; 2d ..........ma.; M.1n Soil to. 5—foot depth .................... hc�w kn o,;m .............. ;.eTests made by.... ... ............................ .when............... "A 'r I.. BSORPTION PATE al I owed ... ­... g.p,s.f.p.d.; Ch�rcked by.— ......... It 4 0, I ,c 7101238 4LLEY ...... . ........ 4 V� ces; -Carmel, Jv v . - STRUCTION F'P I T R tVAU V1 su -SYSTRsk -4 own or a , —W� —006 Lot GwnM` LE DOW Address ... . . . Y, Area —777 ',Total, Habit Bole -Spa Qvstem i c Tank 1 . . A J 0 icb 1i I - A; r I ;j . . . . . . . . . . A 0 Ih su 4sf 4jr r: Ossi9nf by I derj1jh4 ;q., said aewaye disposal : :ysterrl dyging'trye period oftWo (2)., ears:lromeo ,truct jon,Pornpl14q;p1 fys sm or any4r4pa (#.tofr drilled Well'gQser.lbqd' thvi�� 0 11 in# f I L14a rocaiwith, , the Itj dit. W- "0 9t Mn lt9:,Iuu il`' '16sil b;50-'Uctlo ' u of f Commissioner g r vats t Supply only r M-4 41zli 4r... , W--v RFly"'. �*-rh= M, SOILTESTS: let . . . . . . . . ... o Min min. .......... min. Pi .Soil to.5—foot depth ........................... hpw known.............. 'itTests made ............. when. .... ...... o ABSORPTION RATE allowed ........ g.p.s.f.p.d.; Che'ckea by ............. 1. 4,F4 4 ON THIS ce'l. - g-, 93. 07 4 BEDROOM RANCH 86.0.5 14 j O 60 Ufa b Sr 1200 TACONIC STATE PARK COAWISS 10,yjjvo ZngilMe' J-0170( no rye PARCEL SHOWN ON 5tj9D1mlov A AL Sl! WOWN 4 t1 O' T AQ 'W CAY jr SYS is Yp I" 9S BE • 4 RFRAdR.47ED APP OR FOU44, 4'So-.,,l rA� i� J!jtl 15 .ROVED BETWEEN 4 Z745-r."94 ! PtPE To BE ;ISsr, mouse a rAvv 8--:14 DER To, KEEP PRO. 'ED SIFPrIC 41PE4 MAYO A72 :DEBRIS AiVo TO A s vs 7,64 is �., , RnEvr ERoslor". AZ L COAZ; r.�aV TO 4-00AIE Is 4 cro,?,^- V"" ED SLI4 tT.-N. 40NVMEM mum so=. DESIGN: 300 CAL. PEA, BZ-ORO "-' -' R- X 4 &EDROoAfS APPLIED RATE (/ in/ 100 /I *, 7 6,2/5." 7*ReVr4yES_.pj6 0 _,36 L.F PC 4N OF PRA WY Apt ER `:577FIN ERN fe 1 17 TIVA N - V,4U,�t- y rNA COUN7- Jv-r vT jy PROFILE O 24 , PA Rr CL N �o VERT WELL O.,aWAY EXISTINUOVER 100,rON E L EVA PARCEL ER AT T AQ 'W CAY jr SYS is Yp I" 9S BE • 4 RFRAdR.47ED APP OR FOU44, 4'So-.,,l rA� i� J!jtl 15 .ROVED BETWEEN 4 Z745-r."94 ! PtPE To BE ;ISsr, mouse a rAvv 8--:14 DER To, KEEP PRO. 'ED SIFPrIC 41PE4 MAYO A72 :DEBRIS AiVo TO A s vs 7,64 is �., , RnEvr ERoslor". AZ L COAZ; r.�aV TO 4-00AIE Is 4 cro,?,^- V"" ED SLI4 tT.-N. 40NVMEM mum so=. DESIGN: 300 CAL. PEA, BZ-ORO "-' -' R- X 4 &EDROoAfS APPLIED RATE (/ in/ 100 /I *, 7 6,2/5." 7*ReVr4yES_.pj6 0 _,36 L.F PC 4N OF PRA WY Apt ER `:577FIN ERN fe 1 17 TIVA N - V,4U,�t- y rNA COUN7- Jv-r WELL COMPLETION REPORT 3/71 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by well driller and submitted to County Health Department together with laboratory report of al�alysis.of,.water sample indicating water is gfsatisfactory bacterial, quaUty; bere, cetifir ~ate:.of�cos #rlwetiocomtance xs,iscued,; anal. is. way ins y a I REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION I OWNER NAME ADDRESS, ((fTown�) e /j LOCATION OF WELL (No. &Sheet) (Lot Number) PROPOSED USE OF WELL DOMESTIC PUBLIC ❑ SUPPLY BUSINESS ❑ ESTABLISHMENT ❑ INDUSTRIAL ❑ FARM AIR ❑ CONDITIONING ❑ TEST WELL ❑ OTHER DRILLING EQUIPMENT ❑ ROTARY COMPRESSED DAR PERCUSSION CABLE El P PERCUSSION O(Specify) CASING DETAILS LENGTH (feet) 7DFAMETER (inches) rf WEIGHT PER FOOT 7 � THREADED ❑ WELDED DRIVE SHOE ❑ YES ❑ NO WAS CASINGjUTED? 0 YES U NO YIELD TEST 1:1 BAILED El HOURS PUMPED COMPRESSED AIR G.P.M. YIELD (O.P.M.) �i- WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) DURING YIELD TEST fleet) Depth of Completed Well in feet below Land surface: �' 3 �) SCREEN MAKE LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: Diameter of well 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 If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED DATE OF REPORT WELL D LER ( Sign a e I 2 WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by well driller and submitted to County Health Department together. with, laboratQrv,_r�porxraf_ .. ... T analysis of water Sam .,le_indicatin Water, is Qf Sails# r xc?r �.ba '` 'a n y p - g, y , .k ute i�l aauality afar certificate `OT cbns`irilcfion'compliance is Issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NAME ' ADDRESS LOCATION OF WELL o. a Street) ;tiX`� ✓Gr7f i 6Z_- ,TL,47, (Town) (Lot Number) �'1 2 s y .. '. e'', PROPOSED USE OF WELL ® DOMES, PUBLIC ❑ SUPPLY BUSINESS ❑ ESTABLISHMENT ❑ INDUSTRIAL ❑ FARM AIR ❑ CONDITIONING Cl TEST WELL OTHER ❑ (Specify) DRILLING EQUIPMENT D ROTARY (� COMPRESSED Lj -AIR PERCUSSION ❑ CABLE PERCUSSION ❑ OTHER (Specify) CASING DETAILS LENGTH (feet) r DIAMETER (inches) C r/ WEIGHT PER FOOT i " f THREADED ❑ WELDED DRIVE SHOE ❑YES ❑ NO WAS CASING OYES GROUTED? LJ NO YIELD TEST ❑ BAILED HOURS ❑ PUMPED V-3 COMPRESSED AIR G.P.M. YIELD (G. t? 4, WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) DURING YIELD TEST fleet) ±Depth of Completed Well feet below Land surface: c SCREEN MAKE LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: • Diameter of well including ]GRAVEL gravel pack (Inches): SIZE (Inches) FROM (feet) TO (leaf) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. FEET to FEET t � _ j cl 23e Z�e u_ All . MrY_v.'Y - V ..... :..+. .. -. . • o r .. If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE ATE WELL COMPLETED DATE OF REPORT WELL DRILLER (Signature) ) ' r i "~ Otaner or`Purc has, r of Building Municipality Building Constructed. by Section Location - Street Block Building Type Lot GUARANTY OF SEPARATE SEWAGE SYSTEM 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 sewage disposal system, or any repairs made by me to such sys.tem,.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 undersigned further agrees to accept as conclusive the de- termination of the Director of the Division of Environmental Heal.th.,Ser -- vices of the Putnam County Department. o.f .Health, as,"to rhe: her or iibt tie' _. fai_lure-of , ioF -.sue ste o operate was caused by the willful or negligent act�bf_Tthe occupant of the building utilizing the system. Dated this L..,Z day of �8-x 197Z Signature _j Title If corporation, give-name. and address) THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health rw 77- rs D 7 TC Da e : ?ropy. c T Sec BI o c --21 Loy' Gent T 'Ln s 1 e t I s 3 -;D 172 HO G e - fn o 1 �a ILL7, 'Educc-at--Ion LaT..., t-alry Code. Very v (0 rs.. c7n 0 . c u fl- Coun, e!'Si a., e c- . Tele�rcn Acid- e s s V, P m t S—z 1 7 3 ILL7, 'Educc-at--Ion LaT..., t-alry Code. Very v (0 rs.. c7n 0 . c u fl- Coun, e!'Si a., e c- . Tele�rcn Acid- e s s V, P �14. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORMATION I Name of Project 7— �r "' j L v, (T)M Y V TM# Year of Construction Size of Parcel SECTION . TOPOGRAPHY (Please check all appropriate boxes) 1. 0Hilly ❑Rolling CLeep Slope UGentle Slope ❑Flat 2. ❑Evidence of wetland []Low area subject to flooding ❑Bodies of water ❑Drainage ditches Mock outcrop a P YES NO 3. Property lines evident? . ❑ 4. Water courses exist on, or adjacent to parcel: 5. Existing individual wells within 200ft of the existing SSTS? ❑ SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A evel 0 Gentle Slope 13Steep slope B. ❑Well drained Ch oderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) C3 Extremely limited C3 Somewhat limited Mdequate ft x ft D. INSPECTION Date Z� (� � OK-01'e'vidence of failure ClEvidence of failure Ci Inspector DEvidence of seasonal failure -------------------------------------------------------------------------------------------- (Indicate North) HOUSE < eo (1) Indicate location of SSTS A. Size and type of septic tank _ gallons I 13Metal ®Concrete ®Plastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) lndicat�'setbacks, front'stfeet- btickyaYd' aft'd 0d or dimiensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes rock outcrops, streams/wetlands) SECTION E. EXISTING WATER SUPPLY ®PWS []Shared well ;1-ndividual well []Drilled ODug OCasing above ground COQ 0,TENTS: REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: r . . I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ,ENVIRONMENTAL. HEALTH :SERVICES. COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 ':.DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM Owner 6te er. �5 *7� /iyo1_z-e Address 7 D�1,/VN6 Located at ( Street D,Pi„iG. I- As Sec. Block 6dicate nearest cross street) Municipality j�c;� -�;� L�,�� Watershed FILE NO. Lot 2a SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS - 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 5 / G .` 6f- g eJ -its' 5�" / �' / G.�G! ii ,/ %y a /Q ;),Al / it 4 5 Notes: 1) Tests to be repeated at same depth until apppproximately equal soil, rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES f DEPTH +HOLE NO . s HOLE NO.. _, z• - HOLE NO G.L. 6'1 a // 12" 18" 2411 3011 3611 42" 48" 6011 rf 0'6" 7211 7811 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO ,WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY .� ,�yE�/.�1-' C� lele Ejlr�.e �r co, Date <1C7 ic9. /971 DESIGN i Soil Rate Used /0 Min/ 1 "Drop: S.D. Usable Area Provided No. of Bedrooms 4" Septic Tank Capacity /2C�a Gals. Type Ct,IVG, l Absorption Area Provided By >& L.F.x2411 3"6"- 4 width trench. Other I name `l= j,��,2 Address THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: ure . SEAL Soil Rate Approved 1.7 Sq. Ft /Gal. Checked by t P4RCEL B i:• ' UNDER : CONS r - - '83.07 ' ' FR:OW r' B6.Ob a " zi,�j oat ^ O O' 0 DR/NG. - O .00 LANE ,PARCEL. SHOWN.. HEREON KNOWN 4S P4RCEL. 23 ON +MAP NO. / OF GL£N- BROOK; f /LEO. WV, 141 1952.45 Af►.' l o 680..' i'• SURVEY OF'. PRO r AOR BERT /FlEO ro 'FEDERAL ` RCIBERT STENDLER � ;P))?$f- SAV. d L04N. THE COMMONWEALTH L4NO rl rL£/NSUR. CO.OF N Y INRYAil2P,ENTER ;& ;:'.ENQIJNEifitS 6R L"i$ iuA EY01t� k .' N, HEIGHTS; IVY TOWN OF ,PUTNAM VALLEY :....- z 9 �/ PUTNI M !COUNTY, N. y FROMMHOLZ: p. E. S: 12400 SCALE: L":a /00 ^' DATE: OCT'.`/S, /97F I BUTTON CO.; N. v.' NOV 30, /97/ I5400� - 0 o rrgo !D P D OMB W . �R`SFi e loo Z i l /4z z °� X11 IL Z Lb � t'RIDGE �RA Oil PROVOST PL lii ©I1 c c,° I cTAC N �c 1 ROAD~ GAT - .. 4 �r.G�C4 J 2. . ' U r � r � p , � U - �, I . � �+Y- btfd3�9 Lsm�Ataa.27F r �i RTE 6 / LOCATION PLAN