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DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
ADDITION APPLICATION - (RESIDENTIAL ONLY
BRUCE R. FOLEY, R.S.
Acting Public Health Director
STREET: vw r 17 TOWN rt-A i Ix rwr 41 1 t - 1 i
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NAME: �. =L CtJ PHONE O-1 9"-l'32v PCHD PERMIT #�
MAILING ADDRESS Pi fs 4
Description of Addition
Number of existing bedrooms J Proposed number of bedrooms �?
Any addition which is considered a bedroom requires formal approval of plans
(Construction Permit) prepared by a Professional Engineer or Registered Architect
in accordance with applicable sections of the Putnam County Sanitary Code.
Please submit this form and the following to PUTNAM COUNTY HEALTH DEPARTMENT,
4 GENEVA ROAD, BREWSTER, NY 10509, [P��ho����ne 278-6130 with the following information.
1 . Certified Check for $100.00. (c: 7' -t rVL-r-e j
2. Sketch of existing floor P ldn ( all living rea including basement, y)
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Non - professional drawing is acceptable.
3. Sketch of proposed floor plan.
Non professional drawing is acceptable.
4. Copy of survey showing well and septic location, to the best of your
knowledge. Include date of installation if known.
Include all wells and septic systems within 200 feet of property line. Any
questions please contact this office.
OFFICE USE
Comments and /or conditions
applicatio
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BRUCE R. FOLEY, R.S.
Acting Public Health Director
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130 September 13, 1996
Lisa Barbarita
148 Cross Road
Patterson, NY 12563
Re: Addition - Barbrita
No increase in number of
bedrooms - 148 Cross Rd.
TM #10 -1 -10.1
(T) Patterson
Dear Ms. Barbarita:
I have received and reviewed the plans for the proposed addition
to the above mentioned residence.
The proposal for the addition has been approved as per plans
bearing the latest revision date of September 13, 1996 and this
Department's approval stamp.
Based on the information submitted, the above mentioned addition
is approved with the following conditions:
1. The total number of bedrooms must remain at three without
prior approval by this Department.
2. The area of the existing sewage disposal system, and its
expansion area, must be maintained.
3. All plumbing fixtures must be updated with water saving
devices, i.e.,new low flush toilets, restrictors for shower
heads and faucets, etc.
Any other permits or variances required are the responsibility of
the applicant and the jurisdiction of the Town of Patterson.
If you have any questions, please contact me at your convenience.
WH /jp
cc: BI (T) Patterson
Very truly yours,
William Hedges
Sr. Public Health Sanitarian
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OWNER' S NAME Lk 's
SITE LOCATION
!MAILING ADDRESS ( _"Ob
PUIIVAM COUNTY HEALTH. DEPARDOM
DIVISION OF ENVIRONMENrAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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PERSON INTERVIEWED PCFID Canplaint #
Name &Relationship (i.e, owner, tenant, etc.)
DATE TYPE FACILITY
PROPOSED nSTALLEt S auJ E"lries& ..a PHONE fs? 3: - 3 /
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NOTE: 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 app __ Proposal Disapproved
s 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 ramp.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points (e.g. ,house corners)..
d. System descr- iption (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 r ported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE [Z' Z
IBIS: White (PAD); Yellow (fin ffi); Pink LzWlimnt)
PC -RP 97