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Home My WebLink About0105DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.20 -1 -11 BOX 2 00105 ., , ' J. �r il r 7; .6111 6 00105 9 / b: .. •a. ^��I •v�"C PU1L`I!' M COUNTY HEALTH DCPAR24M '+1 DIVISION OF ENVIRONMENTAL HEALTH SERVICES * 225 -0310 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR w Y� OWNER'S NAME i�il( -P h 6 PHONE STIR IDMTION 109 T Md,L J -2A -ffP 1,cv�, /7 70 MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint Name & Relationship (i.e, owner,tenant, etc.) DATE 'I t L� `'l 9 TYPE. FACILITY PROPOSE) INSTALLER h cQ a I I SA-41 L111 -1 t PHONE Z- -7 5 $ fi o 7 Pro (include sketch locating all adjacent wells): NOM: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal fran licensed professional engineer or registered architect. Proposal approved _ Proposal Disapproved Inspector's Signature & Ua 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 canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE DATE ?i G OM IS: White (P ID): Ye11cw (Ttkn HO; Pink (k#i,®nt) oughkeepsie, New York I ip/ DZC 3.6M +(12' +-) 7 +853.9± 7 +850.3± 43:2M± 43.OM+ P.E. (I 25 AREAS 127.8± SQ. M. ERSON MATERIALS CORP. (REPUTED OWNER) / / o / 7 +856.781 6.665M / 76 °- 45' -50 "W / .4M +(11' + -) / PAR. 125 ; 4+ / / ROSE HENDERSON (REPUTED OWNER) ,d ( �I (RE P TED OWNER) TAX J�P INFO: MAP 3. BLOCK �Ek FEE (1024 H0. N76°- 45'-50 "W 3.4 + 15'?MffSp+l HWY, 80Y t 70 7f • � S•ff. sB6 T X860 STREf T . e SCALE 1:250 FOR CONVERSION,OF METERS TO U.S. SURVEY FEET MULTIPLY METERS BY 3.280833333333 3 O 7 +868.6+_ 7.— 0.2M +(1'+) 0 /1D DAD I ROSE RINALDI, JAMES J. RINALDI, SALVATOR C. RINALDI AND ROSEANN SCHWARTZ (REPUTED OWNERS) H0. 5 M +r %r N C9 N � Cp r+'7 1 i� ,p o �Ek FEE (1024 H0. N76°- 45'-50 "W 3.4 + 15'?MffSp+l HWY, 80Y t 70 7f • � S•ff. sB6 T X860 STREf T . e SCALE 1:250 FOR CONVERSION,OF METERS TO U.S. SURVEY FEET MULTIPLY METERS BY 3.280833333333 3 O 7 +868.6+_ 7.— 0.2M +(1'+) 0 /1D DAD I ROSE RINALDI, JAMES J. RINALDI, SALVATOR C. RINALDI AND ROSEANN SCHWARTZ (REPUTED OWNERS) H0. 5 M a_ a r SEE WETLAND NOTE ON DRAWING N0. GI WETLAND NO SEE GRASS STALE DETUI SCAPEROTTI. JR. ED OWNER) PgTERSON MATERIALS 1 CORP. (REPUTED OWNER) P SEE DRAINA OUTLET M9 A70N DETAIL 12a 2 I FEE \ A P�1 FEE :T r DR U99 U 3y P123 I DR � I i I ' 35 qd i r 32 fTl. :R) .D GAS MAIN WORK TO OMPLETED BY OTHERS. 1 HATIALE CECKDAM W1 ma 0 T.E. FEE , I M102 W8 P12T TOWNERS CORNERS - COUNTY TOWN OF PATTERSON JPUTNAM COUNTY O N N 298000 t CAE 12 DATA R 175.00 m —BARRY K DANIELL ( L 49.138 m e ' 0.05 PI03 BERNARD KUEHL —BARRY K DANIELL (REPUTED OWNERS) T.E. '1a 1. PI03 {{ {1 {1 11 � . ��Ri7C�C:ca� • ti I OR FEE 34 HARTZ PROPERTIES. INC. (REPUTED OWNERS) w I 35 R 450 RCP 22m 136.26 134.88 134.89 134.89 I 134.84 {1 1 I NYSELG 1 NYT O I 1 I ( I U53 I P12 FEE P11 1 1, FEE GARY E. STEPIENSON JULIE STEPHENSON I (REPUTED OWNERS) I ARTHUR N. DOREEN SEMEL (REPUTED OWNERS) I NY ESEBG NY2T86 1 RALPH BU EILEENN BU EPUTED 0 FEE M80 P102 ( IOVE STONE G .L 5 GRADE 3 A A.OB.E. R z2Z979420 9 774 STp45T +909 41 • UTILITY QUALITY LEVEL I` • ALL PAY ITEMS ARE METR • ALL DIMENSIONS ARE IN M AS 6 SIGNATLR GEN S' D PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORMATION �} Name of Project (T)(V) r TM# Year of Construction % �� C Size arcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. ❑Hilly ❑Rolling ❑Steep Slope tle Slope ❑Flat 2. ❑Evidence of wetland Clow area subject to flooding ❑Bodies of water ❑Drainage ditches ❑Rock outcrop YES N O 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. ❑Level I ❑Steep slope B. ❑Well drained ❑Moderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) ❑Extremely limited ❑Somewhat limited ❑Adequate _ft x ft D. INSPECTION Dateispector ®No evidence of failure ❑Evr ence- f failure OEvidence of seasonal failure to -------------------------------------------------------------------------------- (Indicate North) HOUSE (1) Indicate location of SSTS A. Size and type of septic tank gallons ElMetal ❑Concrete ❑Plastic B. Type of absorption area 1. Fields L—Czft. 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. EXISTING WATER SUPPLY ❑PWS ❑Shared well 71fW4Uldual well Drilled ®Dug COMMENTS:-� REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: (addrep) C— ��o A e . ❑Casing above ground PU NAM COUNTY HEALTH DEPAR'nWIENr DIVISION OF ENVIRON ENrAL HEALTH SERVICE PROPOSAL Fit SEWAGE DISPOSAL SYSTEM REPAIR odo o6ddER's NAME C�j La7 o Fit; Cr .� PHONE Z7 •SrS SITE LOCATION /U �l' ' 2T -t Z/' , /Oh7JUSC W FILING ADDRESS _? �� ELIZA tN eAXewtsz. PERSON INTERVIEWED PCHD Caglaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED I STMJM t772't .Siva, ?� REGI STRATI014 # 6 Vy - (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original Different location may require submittal of proposal fran licensed registered architect. /ee S PHONE 174 - u6 c9a! sewage disposal system. professional engineer or .4 l 7P I i kil Proposal approved �.-- Proposal Disapproved Inspector's Signature & 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 oamponents tied toltwo fixed points (e.g. ,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. cond tions. SIGN TURE TITLE DATE IP1ES: tthftie (EM): Y,e]1cw (Tatin BI); Pink (Applicant) PC -RP 97 b �Z col T �di571G� c�L 1�K7'�; .r l ar �Or :v�r�r. gat sp.ic tank .