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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
AnT uss: 5-1 AJ, Y
Street Town State Zip
PERSON IN CHARGE nn
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Name and Title
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Signature and Title
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I acknowledge receipt of this report: SIGNATURE:
02/96
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OY DEN-'- l New York City
Department of
~P)
Environr ntal Protection
SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR.
DETERMMIATION .
Pursuant to the authority granted under:
Article 11 of the New York State Public Health Law; Rules and Regulations For The
Protection From Contamination, Degradation and Pollution Of The New York City Water
Supply and Its Sources, 15 R.C.'NY Section 18 -38 (or Chapter 18); and 10 NYCRR
Appendix 75 -A Wastewater Treatment Standards - Individual. Household Systems,
Putnam County Septic Repair Program Flan — March 2005_
OEP Pro.ieet#
PCHD Repair# -� "�) L/ 1- u 4
Site Location: 5-7 T.M.# 3, --. L-
Reason for Joint Review:
Drainage Basin 200' of WC/Wetland Repeat Repair in 5 Yrs.
Name of Owner:
Owner's Address: 5- 1 f,.,%, f -e d-
Drainage Basin of Project Site:
Installer: %--V A^ ` - ?6,
General Description of Sewage System Repair:
/� C e (.�
Dates of Site Inspections and Soils Tests:
Approved *Incomplete Delegated "Denied
**Required- Soils 'Pests Repair Sketch. `VV'CNIetlands_ :� / Wells L,----Other
* *Reason
Determination made by:
L-�v 10Z;3 /Z,�
Engineering Division Date
10'd V I : 9 L 9007 C[ 00 5'US0- ALL- Vl6 :x8A
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PUTNAM COUNTY HEALTH DEPARTMENT o
DIVISION OF ENVIRONMENTAL HEALTH SERVICES Z ,
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
] Internal Use Oniv
❑ �epair epair Permit issued in last 5 years
❑ within Boyd's Comers, W. Branch or Croton Falls Res.
❑ Repair within 200 ft. of a watercourse or DEC- mapped we)tani
SITE LOCATION
OWNER'S NAME
i_
❑ N to Watershed
Delegated
❑ Joint Review
TM #
PHONE #
MAILING ADDRESS -t�rsA
APPLICANT �� tam'
Name & Relationship (i.e., owner, tenant, contractor)
DATE 10� v FACILITY TYPE PCHD COMPLAINT#
PROPOSED INSTALLER AMOX )f 06,WO71 , 1 c j PHONE # 97
ADDRESS (c) 0,9 REGISTRATION /LICENSE # o t�
Proposal (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: Repaie must be in same 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 agq9t o�qwnyrtng
SIGNATURE
Procurement: of any Town Permit, if applicable.
r rr
t+ .c% -i-
stated on this form 0-76 -61340
✓ I
TITLE
,r -,��s DATE
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 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 repair to be performed in accordance with the
above proposal and conditions.
Proposal Approved __� Proposal Denied
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axt — iv e.7
Inspector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
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3.20
PRELIMINARY SCALE--7m 1 a0'
TOWN OF PATTERSON 1 0 - 10
PUTNAM COUNTY, NEW YORK DATE OT AERIAL MVTO�' W °4'10'"7 OAT
NY STATE RME COOIIDINATO
i
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
November 1, 2005
Amaxx Cameo Inc.
124 Route 22
Pawling, NY 12564
To Whom It May Concern:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT I BONDI
County Executive
Re: Repair — Incomplete R- 305 -05
59 South Street
(T) Patterson, TM # 3.20 -2 -1
Review of plans and other supporting documents submitted at this time relative to the above -
regarded repair has been completed. The following was not submitted with your application:
1. Please note that this Department's information indicates that the above referenced lot has
a private well. If this is incorrect, please submit a letter from the Town of Patterson
indicating that it is served by town water.
2. Well locations for the repair property and neighbor's properties need to be shown on the
proposed plan. Please show the distances from the existing wells to the proposed repair.
Upon receipt of a submission, revised to reflect the above comments, this repair application will
be considered further.
If you have any questions, please contact me at (845) 278 -6130 ext 2261.
GR:kly
Sincerely,
Gene D. Reed
Senior Engineering Aide
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
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
tOPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR ?_
Internal Use Onlv
❑ Repair Permit issued in last 5 years Et in Watershed
❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION' `pr,,�� i�9ar�sa.� TM # --'
OWNER'S NAME E,c„n �,,.,i PHONE #
17 .,..
MAILING ADDRESS
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT # �-
PROPOSED INSTALLER ��',z n� r �,.,,�� „s. �A ,- PHONE # _ rP yf-,P 7F-<.ano/'
ADDRESS .1.2 /�?7 2 REGISTRATION /LICENSE # AC��1�<f
Proposal (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: Repair must be in same 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 o o the conditions stated on this form
SIGNATURE / TITLE DATE
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 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 repair to be performed in accordance with the
above proposal and conditions.
Proposal Approved Proposal Denied
Inspector's Signature & Title
Date
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05