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HomeMy WebLinkAbout0123DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -2 -1 BOX 2 1: i ' 1 I r I I T �I ALL I 00123 of Sheet _L 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 QR TNTFR VTF.WF.Tl• /QMd -Y-se LGtwiec 1 0 - oG, T)atP' io / �� %D e,- Name and Title TYPE OF FACILITY • FINDINGS: pp 1�?Se�PV`e� e� J c� L4A it /occz -f lou �X�c t ,�,� GUc� // s�v�;� .A��'� ��`m� s.�,� i� /a ✓l, ylld �f�� w�lr� TNS PF.C'T()R�, - �� ' , �� TFT . Signature and Title RFPnRT RFC F.TVET) RV• I acknowledge receipt of this report: SIGNATURE: 02/96 ' I 1 I I I I ILA { / -1 -_ ! 1 ; /' /S_ i �JC✓t %� i6�_./�' I /ni r -J i P - l- 1Cl.CiA�' _- I _G Vol � �- - ,- - - r , I , 1 I j - - - -- - - ----- - - - - -- - - - ' I I _ N N," 1 , I 1 1 i � UP ! t - i- I -` - - I T d J0 1hJ3Wl lk1d30 J1Nf10J WJrJlfld :3WtiN T2bL- 8L2 -Sb8 X21 trT Ia-� ' 002 -ET -iD i 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 C -Al .......... AV � t j I J ?p�. 9ry yr � I • 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 i axt — iv e.7 Inspector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML 29 40 ° 30 20 e n 66.18 18 19 m 9 51 55(5) 70(S) 62 5 551 34 Ie N w s C" N LEGEND STREET 3.16 T5 130 too 56 • m OEVELWM LOT KWW r DEED DIAET151ON 100(D) 58 57 .. —•• —• —• e ° 55 " 13.07 54 ° - -p —S -- — — OALGR m ANA 2.34 LC. DAL VISUAL CEMIflOID ` oABYIl "w _ T2 125 53 , 59" 51 52 ' 10° wo 10 -0- STREET CENTER Ts 7015) 139.7010) 49 ~ w 60 50 w o ° eaz01B) U I6,.... 40 e I 61 _ � 105.3 I 147.05 47 46 149.10 45151 8315) I AVENUE [UMBER I BL79 193.22(01 63 45 - I' 46.65 101.65101 « N 5 6Q 35.49 'W" • r T1.94 43 9 44 65 143 49.5 651 S) FIRST STREET I Pilo s0 115 674s.s0 r e 42 • 41 • r A 6890.SO 40 f I 69 , 3310 67.0 71 q cl:° Ly, I147.5 — — )9.27 . R i DENISE AVENUE 331 I 70 _ 3.31 AC. CAL. C5 0 u7 I---------- -- w s C" N LEGEND 3.15 3.16 ............••• WETLANDS LINE,AND SYMBOL ..J r..� OEVELWM LOT KWW r DEED DIAET151ON 100(D) 3.19 .. —•• —• —• SMED 01WISIDN Im S) 13.07 1 3. oa - -p —S -- — — OALGR m ANA 2.34 LC. DAL VISUAL CEMIflOID ` oABYIl "w _ T2 Z R lk- a Q Q R 3 I 1 Plg �IW _N 29T4gWM N 976000 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 1n ---- 1. -1 /OAC% X1^0 /— A Y!___ In A11 — 11— c Wb oo i 61 I I 1 I; I , l• IV 0 7Q�e 2S fi Al �d ncm l` 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