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HomeMy WebLinkAbout0404DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 IFF% IL 13. -3 -50 BOX 5 00213 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF. ENVIRONMENTAL HEALTH SERVICES PR POSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES N Internal Use Only PERMIT # 1`) - ❑ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. P&�_ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION `3� p.�vr rG I��� TOWN ���- �,, -,-� TM #) Z� �e 13 =�© .OWNER'S NAME Ron PHONE # MAILING ADDRESS nn APPLICANT -Souk g res'e o �^I.ta4cc:ae Name & Relationship (i.e., owner, tenant, contractor) DATE �c �S'" FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER Sgtiq &.3 � , PHONE # 8 IT �5C- -,S_ ?9'Ge ADDRESS y��o�tn � e/ REGISTRATION /LICENSE ,# 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 system) NOTE: The Department may require submittal of proposal from licensed professional dependinJonn e nature and extent of the repair �S7a� a6 I, as owner,agrel t171he conditions sta on this form PtLc. ;C- pJ'310z14 e-A 665 y;,;�•� �"'"� SIGNATURE TITLE DATE VdWX (owner) I, the septic installer, agree t' omply with the conditions of this. permit for the septic system repair SIGNATURE <— TITLE DATE (3L (installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. (`2. . ubmission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the 6 ; completed SSTS repair will function. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pro osal Approved Proposal Denied ❑ In ector's Signature & Title Date Expiratioh Date Repair proposal is in comp liance with applicable codes Yes No ❑ COPIES: PCHD; Owner; installer PC -RP 99ML Rev. 2/07 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF )ENVIRONMENTAL HEALTH SERVICES ]DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address.... -)61 Located at (Street) 361 Tax Map Block Lot (in4icate nearest cross street) Municipality Watershed U00?0-- L bV07voss P&2-6 J, SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test LIl i �o "Y � gL6 I'll I J )TES: 1. Tests to be repeated alt,,"sfme. depth pirtil,appr6ximately- equal percolation rates are obtained it each percolation test hole.. (i.e. s 1 min for 1-30 mfn/inch, -5 2 min for 31-60 min/inch) All data to be -submitted forreview..', 2- Depth measurements io$6. made fromi -top of hole. Form DD-97 �r. TEST PIT DATA 2 DESCRIPTibN OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. 0.51 1.0 1.51 2.0' 2.51 3.01 3.51 4.01 4.5' 4,1 � o G 5.0. 5.5' .78.0 .8.5 9-0! 9,3 Indicate level at which groundwater is encountered Indicate level at Which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Design Professional Name-.. Address: Signature: Design Professig,fial's Seal r �t - .s 1.. .::��sa:-s, � t' +•! ,'' �n��lr'`. .w - �: as ���P CS+� G-i r `•�2�.+ 3 �, �]• fT'33' -::,.. F1�', �i �;. ryai�l�i .�.ri��ri�r:rl�•�w�r..��,� '� _ �Alfy'�RLf...1 -.�' : :orJ 20�D �5 I.J _ `•�; RDAD LF u' ����� (dr+Q+'sLgi�S 5 -V }, -. _ •z si +�" , y i. r v`7 FLt TURK ROAD v 4 ': a3Fi x kl, ,. r r',r '-a�, �' o- 4. [ »r •a.,rs.. � .ems Y �t � fi> .+ /��, +- ._..+�...� r$ ,a f , g .t -..- 'x - - •�.� T-.ses.R•,'s. t � - s,F '"'� � �CZ '` . �'tf`•Fiw utti "4f .. � - � ^' ry :� v �i 1 -. ,y' .aa - .?�r.aii PX t T � > 1 1' JT G' J- a -w...+ .tq 1 > t. � y i •. 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V ei • V1. n', ro nj M�, 6.A.- q wr J7 zi; t-y- Z -7. kil Y;ij rs Y. r. :7t YG- gnaI: . . . . . . aT ". L jar. IYAN- , r "g • CI .�j% -4.2-v. -qif J. �v cl r. 4F . ..... . ZE 14' zo 02 1- c it t r 4&4 4 cs 4 )Nov YLQ 4 ;IrA SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 FACSIMILE TRANSMITTAL ROBERT J. BONDI County Executive To • 04ulp'll )f 0 Fax: ._y -3 `y 3 From: Joe %���� ���P H ]"r. �k�"1 �' Date: 3 Lc�221oe Re: P «<Y a t 3 rowdl lQ1 iU Pages: CC: ❑ Urgent For Review ❑ Please Comment ❑ Please Reply 'foe- 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 not 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 MEMORY TRANSMISSION REPORT TIME MAR -27 -2008 01:35PM TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER . 730 DATE : MAR -27 01:33PM TO 919147730343 DOCUMENT PAGES 003 START T:!"P MAR -27 01:33PM END TIME : MAR -27 01:35PM SENT PAGES . 003 STATUS OK FILE NUMBER : 730 * * * SUCCESSFUL TX NOT ICE * * * SFYEY2LT"CA AMLEI2. NLD, MS, FAAP tL �C ROBERT J. IION61 CpmmisrFpa¢r q/Weplth do -4-- Cp�ttl q+ E'xccutivc• L!x.Jr -- r^ N1QLiNAR1, RN, MSN Aoclata COmnitSSEOnf!r pfH¢a lth W tDEPARTMEEVT C)F HEALTH 1 Geneva Road, Drowster, N`tw York 1 0509 FACSIMIL� -EI TRA.1V'SMI�IT�TA.L T o. D!.( ✓1✓�_�t Piaj �o o✓ ��Va_!./i [oi4 rsg� •' Talc: 14<— -:1 7 3 —o -3 4 3 From: Sow .�,�a•�: ir. /�AI+E Datz: 31--27Zo.- _.._ CC ------' ..........................................................•..........---...................-•---.........----- O Urgent �_ For Review C3 Please Comment O Please Reply Pl. _ / 1��-N -. T �'L h--� lea '�" t`5 rya. -lam• _c �.e .mil CONt•LUENTYALT'r'V STATEMENT: Tile information contained in this facsimile may contain CONFIJ76NT1AL and legally pl-ottacted information intended only for the l.s-ce of the individual or entity named above. If the render of this rnessage is not the intondcd recipient, you are hereby notiiied'tbat.any dissension, distribution• or copying ofihis releeopy is strictly prohibited. if yov have received this telecopy in error, please immadintc:ly notify us by mlopllone (645- 278 -6130) and destroy a11 docti —nis associated with this facsimile. Eaviro nan enial I-1—Uh 0845) 276 -6130 Fax (845) 278 -7921 T,4-1.2, Services (845) 278 -6558 Fax (845) 278 -6026 %AnC (845) 278 -6678 Hura lag Etomc 4-W Fax (845) 278 -6085 rinrty lntarventtenfPreachool C845) 278 -6014 F:w (SAS) 278 -6648 , C. ' w. 97 \� >\ r� ' 54 96 9.16 AC- CAL.- _.... ". -. o < 4319 AC.., _ 53 115, 42 i7 a 51 N 83 r 82 R1 80 52 i�\1 27 AC w2t "12 157A ,Sp.9r ,9,.6•I ,a, •�. 7.9 - 7 9 AC. CAL. z9�:i jjt Ate' mµ1 Flt 15 xw LANE s 93 78 F2 49�1.36 AC, ^$ ICC•e7 92 ' e _ S p : CAL. . ,' 89 90Vn 77 \ \1�.• .u�. t.42ALC"'o NGWEW ryE (ro37ix' C.aA 45 _�- 72 1 73 44, a 75 l \ 43 ^... o u. \\`$ 1002A 41 __- _ CAL. - 47.45 AC. 62 O cc - 7p76'3fi5r' Q r j", r _ i PRIVATE WAY _ j '1, K a C',� o j �. � 1 1 10 i 1: Y 51.42 AC. CAL. 6^ IA 7 AC. CAL. 1 zae i � 1 1 1 1 22 1\ 0 8.02 AC. 23 4 AC. 14 iUl ,,3E 55 -89 AC. I N, - :f c\i i a' 1.10 AC. `' 'so w \> 29.6 AC. CAL. 15.2 szat m' 1.{18 ACS+ 65 'y*•, __ m .''.25+ 'E 1.05 AC -- �161e ss 4.32 AC. "17 40�, 17 AC. t SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 REQUEST FOR FIELD TESTING All information below must be fu completed prior to any scheduling. ENGINEER OR FIRM: 2 PERSON TO CONTACT: ICk ❑ NEW CONSTRUCTION KREPAIR PIM ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health DATE: ,3 Os- PHONE #: ❑ ADDITION PROGRAM REASON: DEEPS: 0 PERCS: ❑ PUMP 11 n ROAD/STREET: Jg 1 CD/-A iAZZA1 1 N L' I( t TOWN: par `Leel 1-1 0 l SUBDIVISION: OWNER: �,6 Mat 1 YU0 TAX MAP #:3'7,?YQ0 8,--3-50 LOT #: NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING YES NO ❑ ❑ Proposed SSTS within the drainage basin of West Branch or Boyds Corner & Croton Falls Reservoirs. ❑ ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered L to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: TIME: COMMENTS: REQ. FOR FIELD TESTINGACLY 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