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3.15 -1 -10
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00057
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES-J
Internal Use Oniv PERMIT # 8 v 6� I
❑ (21 Repair Permit issued in last 5 years in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑
VRepair within 200 ft. of a watercourse or DEC - mapped wetland ❑ - Joint Review
SITE LOCATION TOWN e rS0/0 TM # 3,15 – 1 i C7
OWNER'S NAME Se- Lor PHONE #WS `I3 • Y% V�
MAILING ADDRESS 1% ' f- .N.
APPLICANT
Name & Relationship (i.e (owne ,tenant, contractor)
DATE ` _ FACI TY�,T�-Y - PE 0kilI � I PCHD COMPLAINT #
PROPOSED INSTALLER ffz0//7�`at" PHONE#
_ 1
ADDRESS � /0 �? c�Q,_ REGISTRATION /LICENSE # a
Pro al (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 professional depending on the
natur and extent of #ie repair. 0 efs
I, as owner,agree to the ted on this form
SIGNATURE S TITLE, 0\,.,sr\�,e._f- DATE 5` 7
(owner)
I, the septic installer, agr%e to co ply with the conditions of this permit fo the septic system repair .
SIGNATURE y TITLE re- DATE �!
(Installer) ,
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 fixed points f;
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 fit design and there is no guarantee'.to `the duration at whichihe—
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved Proposal Denied El.
Ii sobdoes Signature & Title Date `. Expiration Date
,Repair proposal is in compliance with applicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLII SERVICES
FIELD ACTIVITY REPORT
Street Town State Zip .
PERSON IN CHARGE f�
()R TNTFR VTFMMTI _ / l el f t ,
Name and Title
TYPE OF FACILITY:
FINDINGS:
Signature and Title
RFPQRT RF(.FTVFT) RV.,
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
Ooo Cza.t,
r
,'n 9 f«. ✓el
Signature and Title
RFPQRT RF(.FTVFT) RV.,
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
P UTNTAM COLNTY DEPARTIVIEN-T OF HEALTH
DIVISION OF ENIVIRO-N.-NIENTAL HEALTH SERVICES
DESIGN-NDA,TA SHEET = SLBSL'RFACE SEWAGE TREATvIENNT SYST'E-N,,vf
Owner: —/— Cut swk&Ct et CL Address: 36 A/6(14, —sj
Located at (street)"' TM, 'M' Section: — Block Lot
Municipality: eAhlrovs el Watershed:. J �.-6
SOIL P ERCOLATIONTEST DATA
Witnessed by:
Date or Pre- . Soaking: Date of Percolation Test:.
Hole No.
Run No.
Time
Start—
Stop
II
pse
Elapse
Time
(min.)
Depth to
ater from
ground
surface
Start - Stop
Water
level drop
in inches
Percolation
Rate
min/inch
o,,s 7 - - Ili-A# I
0-2
1j/ 2-
I 3
I 900
2
J/'X6- 16'56
.30
aL j r �3
3 1,U
01
30 I
O- L-- -,L3 Xy
I xyfe
I
4
1 5
1
2
4
2_
4
2
4
Notes:
I 7-,IZ7: rn 'n,- r=np-rzl ar ;P—.p jrr,,r:1 .... ...
:.:: �:,,.: �,..,,......... m.... o�w.... e.,.w:,:M,.u:, >�c.�:,.......,.� s•. i�.,. �. nw: u. r., w�.,...., iu..,....,,. �., is�u:•: iuu., vi+ �e:,,: ww; aw:.., n.: �iu�Y: �c;:,:. ao�.:,:. �u�:. w, y...,, y.., �„¢.:> ,. �. ., e..,...:: n�:, r,.. �.. W, �.... ws,......... �. w,�......:.w.�....y,a.,.�,_,.,. N...,....�...�r .r
TEST PIT DATA
DESCRIPTION OF SOILS EYCOL,+TERED I'N TEST HOLES
HOLY - HCL-= HOLE R HOLE T
1.0
210' e(
2. z Ca
Q
4..
J.V
7.0'
7.5
C 'J'
8.�
Q"
10. G'
L*idicate leve! at which. = oundwaier is encountered Allvl E
L-�dican level at w-uch mottling is obse ^red
Indicate Level to which water les•el rises a<<e bein` encountered
Deer hole observations Made by: Date /G
DesiZn? ProIeSSiOrial Nave:
Adidv�ss:
Mo
84 1 \ NPt'j 1
311
Akin, s
Es
16 S4
ir
The
ialn
Great
Camp
f
64
Brady.
rook —
Pond
Swamp Mo
311
-W
12563
Ice
Pond
Vtil
2 P
16 S4
ir
ndel Pond
164
t
n
C
C) navy
2
moo x
U !quo I Area
BREWS R
HS
OES
Rrvmatar 1 11 f
ialn
Camp
f
Brady.
Pond
-W
Ice
Pond
Vtil
%Y
-W
ndel Pond
164
t
n
C
C) navy
2
moo x
U !quo I Area
BREWS R
HS
OES
Rrvmatar 1 11 f
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 (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
December 13, 1999
Michael Yancofski
36 North St.
Patterson NY 12563
Re: Addition- Yancofski - North St.
No Increases in Number of Bedrooms
(T) Patterson Tax # 3.15 -1 -10
Dear Mr. Yancofski:
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 form this. Department dated December 10, 1999 The addition is-approved with the
following conditions:
1. 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
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 Patterson. .
If you have any questions, please contact me at your convenience..
Very truly yours,
Michael Luke
ML:kg Public Health Sanitarian
cc: BI
0
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
Public Health Director
STREET , /je r T Sl TOWN TX MAP #
-NAME , i'ti C(% 1 PHONE R% J Z PCHD # 7 �J
MAILING ADDRESS 36 /)014� ST[ eet
DESCRIPTION OF ADDITION S i o OT eKS1.4incl,
C»lfuo rv?
NUMBER OF EXISTING BEDROOMS 3 PROPOSED # OF BEDROOMS
(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., 4 Geneva Rd.,
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.
5. Copy of Cert. of Occupancy from Town or Certification from Building Dept. with legal
bedroom count of dwelling-
OFFICE USE
Comments
Feb 98
Y' 1
DEPARTMENT OF HEALTH
.Division, 'Of Environmental .Health Services
4 Geneva Road, Brewster, New York 10509
(914) M -6130
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10501
Gentlemen:
A
I
BRUCE R. FOLEY. R.S.
Acting Public .Health Director
Re: '36 P014h SI ,
Residence
Tax Ma 3 -4 -1 (New 3.15 -1 -10)
Town S o n
According to records maintained by the Town, the above noted dwelling
IS
IS NOT xxx
in compliance:with Town code and the total number of bedrooms on record
is three (3 )
This information,has been obtained from:
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD: xxx
OTHER
Building Insp r
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH. SERVICES
INITIAL IND VUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORiMATION
Name of Project 34 N' f 5 (T)(V) TM#
Year of Construction Size of Parcel
SECTION 'B. TOPOGRAPHY (Please check all appropriate boxes)
1. Of ill / ❑Rolling Ostee Sloe entle Slo e ' ❑F1at
Y � P P P
2. ❑Evidence of wetland Clow area subject to flooding ❑Bodies of water
❑Drainage ditches ❑Rock outcrop
YES NO
3. Property lines evident? ❑
4. Water courses exist on, or adjacent to parcel: ❑ L►�l
5. Existing individual wells within 200ft of the existing SSTS? ❑
SECTION C. EXISTING SUBSURFACE SENVAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. ❑Level L7Gentle Sloe ❑P slope
slo e
P
B. ❑Well drained Mul- oderately well drained
❑Somewhat poorly drained ❑Poorly drained
C. Area available for SSTS. (Primary & Reserve)
[]Extremely limited ❑ Somewhat limited Fo Adequate6 o ft x L/ d ft
D. INSPECTION* Date �L Inspector`
0' \o eridence of failure ❑Evidence of failure (]Evidence of seasonal failure
---------------=--=---------------------=-----=----------=-----------------------------=----
(Indicate North)
Y
th
J
.41
(1) In cate location of SSTS
A. Size and type of septic tank jallons
❑1%9etal ❑Concrete OPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallies ft.
(2) Indicate setbacks, front street, backyard, and side yard dimensions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
SECTION E. EXISTS IG WATER SUPP6In '
❑PWS M Shared well di vidual well
r7lDrilled . ❑Duo' OCasing above ground
COiNSENTS :
REPAIRS ONLY: Status:
As Built Inspection Required: As Built Submitted:
r
As Built Inspection Done: Inspector:
a
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INYrand
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3. 15 -I -.(a
HOUSE PLANS APPHOVED FlIn
BEDROOM COUNT m!1-1;
3 8LDEICj()MS)
Signature & line Date
Y6i n. cA � i'
X07 W
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MEASUREMENT IN U.S. STANDARD THE EXISTENCE OF RIGHT OF WAYS AND /OR EASEMENTS OF RECORD, IF ANY,
NOT SHOWN ARE NOT GUARANTEED.
THE DIMENSIONS SHOWN HEREON, FROM THE STRUCTURES TO THE PROPERTY LINE, ARE FOR A SPECIFIC PURPOSE ONLY. THEY ARE
NOT INTENDED TO BE USED FOR THE ERECTION OF FENCES, STRUCTURES OR ANY OTHER IMPROVEMENT.
UNAUTHORIZED ALTERATION GUARANTEES INDICATED HEREON SHALL RUN ONLY
OR ADDITION TO A SURVEY MAP ONLY COPIES FROM THE ORIGi TO THE PERSON FOR WHOM THE SURVEY '.S PRE,
BEARIBEARING A LICENSED LAND NAL OF THIS SURVEY MARKED PARED, AND ON HIS BEHALF TO TH-- Tli'LE COMPANY
NG A SEAL IS A VIOLA- AND WITH AN ORIGINAL OF ThE GOVERNMENTAL AGENCY AND LE DtNO INSTITOTIO "T
TION OF SECTION IS A SUB. LAND SURVEYOR'S EMBOSSED LISTED HEREON AND 1'0 THE A, SIGNEES OF THE
SEAL SHALL BE CONSIDERED LENDING INSTITAON.
DIVISION 2, OF THE NEW YORK T08EVALIDTRUECOPIES GUARANTEES ARE NOT TRANSFERABL% TO ADD[-
STATE EDUCATION LAW, , TIONAL INSTITUTIONS OR SUBSEQUENT OWNERS.
KVTLHAN�:' K & PLAN SECTION BLOCK DATE
LAND URVE"'73 ;.'E[�r - —/ - '. , '13 • S4
I � GUAR�rJ�r TO
INF9 kIfS1f9OFFIGE:. :114zlS;GEES9 ��j -iVA^A
POUND N!DGE, NY P.O. BOK 178 Tile' 4 ffJ::�3:.1J _�E'�" ✓ /G. f-_ N.O.E fr- .4GC COUNTY
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