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 .. ', . a�.5 .Td, Y�,�' � 1 �8^� L'Q�'F' • 1 fJ //1 l
�� .: "� +_ 1 y`xb 'e�`J-'"ic- �sL�i''cxv "y�`aYi�4 at�v �2'C• �� I i � ry ? '.. +..._ sl .,.+''...'°'...^'*,..,_.
Csaj('Y�.'�` �, .,a f �. _ �� 3$' ,� ,•A —.�tri � y � c � ' • � '' � 'F" s "-i iJ� , � :.
�'a"'' A ME F- .: - ic.S'Y,F yr ,�,�.' G tom. y�.e"^'^.C,c.:• _
j1' ' t f. �r3.F�•.,}.'�r 'U'y�Y2 GNI✓� Ill +mil f ++C - 1./L
,�v,�. &, ;` �.a _ t � �F'�4��xitv`" '�.�" =� j�•�K` � ' � t '� '�- 0.:7���'Y•Y � W� �.] 'f '..� /�' f i� r �+�
Mau w
c zL ^' �Ir.{r�a�- •s,�'�1t"��3
ci
r�.� 3 �f�^ -$„ "y 7.Sf y • •
ONLF
YV
SOv 11, 1 *��•i5y`h�„�y�'�`'�"��4
WNW r.
— ` �4f..
}'� OVIS �`+�`„
i, `R �, 'itir�J i'�`at.?u� �'°K.v •,3- f t � "F4� r,��7
k"f t4y� Y� E., � die -.ya ',i{' {+ �„� z, _ •. � � - yf�° �.�� .,�
F'1 Rr� f r y^ - �*3 xL5'w�'A�' � f f ���,� jj Q �f (� r '�,� - •� •' 1
j"`h.��-�'r .'"'^+•'.�,'��� etr�5�,,^s��,�Y) � ��',�'�r l 4 y Ie 3 ... I��t�r Y.S 4 r �y �i�fy
�cr �a. 4i s f�t 3G
C i�1S�� f b �� r+•
miry .+h � � vr, J�3�" N '.y� +>T `�,� ��'rry•
�'�•3��•''"§ '� `rs',�p[ � r,,��np •: a -A. �,( ,C. - •'� '. `
•`'"" #,.,Y �}-.b �A�yl2 J.�ab t€ �3*4a�FJSW Ji''r i1S � 67 . � '• �`°
�, •s �.�°y£..Wy �� r' .0 ,i¢'+�y1 �'Mati �'. III p`'�'
hy� r e s'*•r +'r:.:da�,x�`x�`''�" ? t a
!!'ui s'!-r I i �`•''
�'c� 'i ?f't.�'
;.K+ty,,t��'L ON �n, r
���� 3'�a -y... _.'.w`.�sr,. 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
,