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HomeMy WebLinkAbout0113DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -1 -34 BOX 2 rL No T k.' dr NN: � Ng" � IN 1''f P. �IN iwi ' 00113 PUTNAM COUNTY HEALTH DEPARTMENT ' 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 1. 2yaa- oe3�t?a�� SITE LOCATION 11,39 TOWN Soh TNJ # 4 o a 10 3Y000 OWNER'S NAME 6•J_�[h2/ar'4 PHONE #. MAILING ADDRESS 2-7 2,000 S000 PROPOSED CCINTAACTOR /INSTALLER PHONE # 7 ADDRESS Q5 V' � REGISTRATION /LICENSE # X13 Reason for exotoraiion: O failure to suilace ❑ back -up In house ❑ find limits of system for repair ❑ other (explain below) r n FOR COUNTY USE ONLY e & Tllle Date r ' <�( ApPointmen# Dams: � � Time: l 3 kty:excetseptic L -d 6869 -6LZ (9t g) IIaPuAi dZE :bO 80 96 oaQ SHERLITA AMLER, MD, MS, FAAP Commissioner of 1'Yealth LORETTA MOLINAFI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 FACSIMILE TRANSMITTAL ROBERT J: BONDI .County Executive To: %Zr.��,� _ Fax: From: S�� ��.��.�al,` j�_ /k� °i +ti' Date• Re: i%1 �/�� �' Pages: CC: i :3� 3r �, Ci) �. jam;. ❑ Uro ent For Review ❑ Please Comment 0 Please Reply CONFIDENTIALITY STATEMENT: The information contained in this facsimile may contain CONFIDENTIAL and legally protected information intended only for the use of the individual or entity named above. If the reader of this message is riot the intended recipient; you are hereby notified that.any. dissension, distribution, or copying of this telecopy is strictly prohibited. If you have received this telecopy in error, please immediately notify us by telephone (845 -278 -6130) and destroy all documents associated with this facsimile. Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845)278 -6014 Fax (845) 278 -6648 SL 441 E wz a � �N col, !t- Ns i J J uy N 1L IL 99, IL SL . . . . . . . . . . . IL Cw- Al O col, !t- Ns i J J uy N 1L IL 99, IL SL . . . . . . . . . . . I NIP C a v t�fi�• 4r�ys' ,} �� k"` }F� jai i : Z�+r I ,. 1, a � 4 '' � ' .n '`�'�- .5- ..t,.. ?.� t.: i' ""' � tYr �.�`. f - u I r ' J'ti,%Ji � 6fi ��<•r �e+}0. r .. 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K .::�y�t(f.N1�3u `�. - ..,.:�.., r. �•h ' , ... ,.'3:a .:...:Sb faF.�".... _, . _ .""f .�Gids"[�.~�..:.,?'� r }�� �sli ._ �t ... ���x.+�` .:'��'A'iz93.yw�Y�k. <. . _ � .. -, _ s.°' X' SITE LOCATION PUTNAM COUW -Y HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES �' PROPOSAL FOR SEWAGEs DISPOSAL SYSTEM REPAIR PIO kftmal use -- epair Penult issued in fast 5 years ,❑Not in Watershed Lor c oton rags Rz& IiJ OWNER'S NAME ,s'f�j MAILING ADDRESS i within 200 tt of a wakwaxuse or weand 1132- & whe- -3/1 Pa P�-s on �nrn «rte ❑ Joint Review TM # 11 PHONE # 979 - a-00 C) _� � fit, APPLICANT / aii ib '56,r '56,r6 Name .S�lr �P�m_ s LvL Name & Reladonship (!e., owner, tenant, contractor DATE D !? FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER �y /� l�s 74 �-,.PHONE # REGiS'TRATION IUCENSE# _ Pro osal (Include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed trenches) NOTE: Repoli, must be in some location and of same type as original sewage disposal system. Different location and proposed pump systems will 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 SIGNATURE6� r TITLE Proposal approved with the f U�, wina conditions: 1. Procutemerit of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owners name b. Site Street Name, Town and Tax Map number c. Location of Installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. installers' name and phone number 3. System rWilr to be performed In accordance with the above proposal and conditions� Pro osal Approy Proposal Denied a In pecta„s Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML DATE o2 zs� D END F'LA5'nG FENCE 1.05' N r ro -51DLE WELL . r. CONC. MON. r r FND r Stow tmi. WALL AIWA— I SS63 5Ft ,:�sx r� n �r 0.422 Acs N/ P 9' r Goa.! m-rFE N.Y: SL -1 ONL IW • i d ` -b.•r� �' *gip �u i x yCY I CONC., 25 �c s 7 TaSzy�' , 4.2ac p 27 �s Yll Fol r • V r .( Pn. 3 Q, i• ct- is /s"C4:.( �" - r r . s (V ' �'• -tom. c•+2af -�+-� a«/k -fl— T, , c its �# k ,fir s n z 4 • �MdUwl�- ., DaOF Q.i33 - � N.X.Q. ...•. 2 — � _ _ :3 PUTNAM COUNTY DEPARTMENT OF HEALTH ]DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM d „� 4 Owner: ' Located at (street): Municipality: Address: 4- TM # Section: — Block _ Lot Watershed: SOIL PERCOLATION TEST DATA Witnessed by: a �i,. r %;j .�'� Yt< r�0'1�- Date of Pre - soaking: I ''6d Date of Percolation Test: '6 p 4 Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch Z ° 3 s 4 , 5 3 r -4 i /' I 3 a3. ' 7 "3 4 5 1 Z 3 4 5 Notes: e7 f5;; bjG ✓, �► Z �2+-d 5 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for .1 -30 min /inch, < 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, pa I of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE #_j HOLE # HOLE # HOLE # HOLE # G. L. 0.51 1.01 1.5' 2.0' 3.0' 3.5' r 4.0' 5.01 5.51 6.0' 6.51 7.0' 7.5' 8.01 8.5' 9.01 9.51 10.01 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: rs P Date I' Design Professional Name: Design Signature: Design Professional = Seal SHERLITA AMLER, MD, MS, FAAP Commissioner of'Health LORETTA MOLINA:RI, RN, MSN Associate Commissioner of Health January 7, 2009 Town of Southeast Town Hall. 1 Main Street - Brewster, NY 10509 Attn: Michael Rights Dear Mr. Rights: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re,: Test Well Permit Application for Springhouse Estates (T) Southeast, TM # 46 -3 -38 This Department has approved the test well permit for Well # TW -01 709 at the above referenced project. The location approved is for the drilling of a test well. Please be advised that if site conditions and /or site plans change and /or are revised, thereby compromising the minimum required separation distances, siting approval of the well must be reapproved by this Department: As stated above, this, approval is for the drilling of a test well only, and a detailed report outlining. the proposed well yield testing program is to be submitted to this Department for review at least 30 days prior to the well yield testing. All necessarY Town permits for the installation of the well are required to be issued prior to well construction. Should you have any questions concerning, please feel free to contact this office. Respectfully, Michael J. B zin Director of Shaine MJB:kly cc: A. Beal Dan Michaud,. Chazen Co. RM AB 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 Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 l r r � N/ F N.Y. ------ 0 � POL-e , / 1j � ---__--'_— cxR.r OWN ,