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Home My WebLink About0494DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 14. -1 -58 BOX 6 LLti SjN%3.v.L ;; , I kq 1 show, IN-9 MIND, me � .♦ J T It r 1_6 �. I 4oi. IV III - I IN ' ■ ,. ,J ,� - ■ I 00303 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES a cl° ❑ ❑1 SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT Internal Use. Repair Permit issued in last 5 years Repair within Boyd's Comers, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC-mapped wetland TOWN ^ AZI qrJ Name & Relationship (i.e., owner, DATE FACI ITY TYPE PROPOSED INSTALLER t/r ADDRESS Li PERINIT ❑ Not in Watershed ❑ Delegated E1 Joint Review TM #_14. " 5P PHONE 34a— 15 72 PCHD COMPLAINT ## PHONE # %7yf7iQ'e7�� 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 depending on the I, as owner,agree to he conditions stated on this form SIGNATURE /V . TITLE DATE (owner) I, the septic installer agree o comply with the conditions.of this permit for the septic system repair SIGNATURE �� TITLE , -e _g DATE (installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission 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 completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved ❑ Proposal Denied ❑ -J- _ `,C Inspector's,,Slgnature & Title Da a piratio Date Repair proposal is in compliance with applicable codes Yes O Nosh COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Environmental Protection New York City Department of Environmental Protection SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR DETERMINATION Pursuant to the authority granted under: Article I1 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 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR Appendix 75 -A Wastewater Treatment Standards - Individual Household Systems; Putnam County Septic Repair Program Plan - March 2005. DEP Project# - -ra A PCHD Repair# A" 6PI --1 IL— Site Location: /72, AV1144 AEI otd T.M.# N, —/— If Reason for Joint Review: Drainage Basin 200' of WC /Wetland_&,-" Repeat Repair in 5 Yrs. Name of Owner: Owner's Address: Drainage Basin of Project Site: `�f K.,L4 Installer:e`""'r General Description of Sewage System Repair: �' `'4 hem At /Q"�k, CLJ f'Ka dyllrti I •J 41 abVve.. Dates of Site Inspectio s and Soils Tests: V'A J-// z... Approved :eIncomplete Delegated "Denied :"Required: Soils Tests Repair Sketch ' "''`Reaso Detenninatio ma by: WC /Wetlands Wells Other Engineering Division Date REBECCA WITTENBERG, RN, BSN Public Health Director ROBERT MORRIS, PE Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MARYELLEN ODELL County Executive TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW GPI "112 FROM: PRIORITY - SEPTIC REPAIR DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM PROJECT: LOCATION: JOINT REVIEW 10) /(jj TOWN: TM # / V NOTICE OF COMPLETE APPLICATION: DATE: y � /z. ❑ Within the drainage basins of West Branch, Boyds Corner, or Croton Falls Reservoirs ❑ Within 500 feet of a reservoir, reservoir stem or control lake. o 'Within 200 feet of a watercourse or a DEC wetland and appearing on a subdivision map approved after December 31, 1992 ❑ Design flow greater than 1,000 gallons /day. ❑ Commercial SSTS. SEPTIC REPAIR JOINT REVIEW Putnam County Department of Health Division of Environmental Health Services • SSTS Repair - Fin I Site Ins ection Date: Inspected by: r . J Installer: Street Locati r 'k, Owner: (' A a i ) Town: [!� i t Repair Permit #: - ! - i -z- TM # 1. Type of System: Conventional ❑ Alternate ❑ Comments: 2. Septic Tank Yes No N/A Comments a. Septic tank size -1,000 ... 1,250 ... other ..... b. Septic tank installed level ...................... c. 10' minimum from foundation .................. d. Distribution Bog i. All outlets at same elevation (water tested) ... J ,e ii. Protected below frost ............................. iii. Minimum 2 ft. Original soil between box & trenches e. Junction Box - • ro erl set ............. ............... ✓ f. Trenches L S stemi pompletely opened for inspection ` ii. Length required Length installed iii. Pie slope checked ... .................... ............ iv. Installed according to plan ..................... ✓ V. 10 ft. from property line - 20 ft - foundations ... vi. Size of gravel % - 1 '/s " diameter clean ......... vii. Depth of gravel in trench 12" minimum ......... viii. Ends capped .... ............................... g. Pump or Dosed Systems 3. Sewa e System Area a. SSTS Area located as per approved plans ✓ b. Fill section - c. Distance from water course /wetlands 4. Overall Workmanship a. Boxes properly grouted and installed correctly ........... b. All pipes flush with inside of box ......................... c. Backfill material contains stones <4" diameter ......... d.' Curtain drain & standpipes installed according to plan e. Curtain drain outfall protected & dir to exist watercourse f. Footing drains discharge away from SSTS area ......... g. Erosion control provided Addit ��b��$� -� � � o � �r j l vo. TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # I HOLE # 2-- HOLE # G. L. L/o /mod 4 atx, e- 0.51 1.0, b4o, 2- avtl %�-- Co l (lie ✓r, �a r-r� v �+r 2.5'ao 3.0' 3.5' 4.0' - 4W�i� .Se try 6.0' . 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' HOLE # HOLE # 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: Date - /Z Design Professional Name: Address: Signature: Design Professional = Seal I ' d P� o Property Details - Image Mate Online Putnam County A6G Image Mate Online Navigation GIS Map Tax Maps Residential Property Info Owner /Sales. Inventory Improvements , Taxanfo Report Comparables, Res. Sites a10 ORPS Links I Assessment Info Municipality of Patterson, Town of ISWIS: 1 372400 ITax ID: 1 14. -1 -58 1 Tax Map ID / Property Data Status: Active Roll Section: I Taxable Address: 172 -174 Haviland Hollow Rd 280- Site 280- Property Multiple Property Multiple Class: res Class: res Site: Res 1 In Ag. No t: Zoning Code: Bldg. Style: Old style Residential Neighborhood: 00200- School Brewster District: Legal Property 00800000010100000000 Description: 006440000000000001008 8 -1 -10 2011- Total Equalization Tentative Acreage /Size: 10.08 Rate: 100.00 /o 2010- 100.00% 2011 - 2011 - Land Tentative Total Tentative Assessment: $89,400 Assessment: $567,700 2010- 2010- $89,400 $597,600 2011- Full Market Tentative Value: $567,700 2010- $597,600 Deed Book: 1477 Deed Page: 64 Page 1 of 2 Help I Log In No Photo Available Ma View Tax Map Pin Property on GIS Map View in Google Maps View in Yahoo! Maps View in Bing Maps Map Disclaimer http: / /putnam. sdgnys .com /propdetail.aspx ?swis= 372400 &printke... 4/18/2012 Property Details - Image Mate Online Grid East: 749176 Grid North: 968694 Special Districts for 2011 (Tentative) Description Units Percent Type Value Park district 0 0 0 Fire #1 0 0 0 Garbage dist 2 0 0 Special Districts for 2010 Description Units Percent Type Value Garbage dist 2 0 0 Fire #1 0 0 0 Park district 0 0 10 Land Types Type Size Primary 2.00 acres Residual 7.58 acres Page 2 of 2 http: / /putnam. sdgnys .com /propdetail.aspx ?swis= 372400 &printke... 4/18/2012 rT:Yy. PUTNAIM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: e ti 610,6 Address: Located at (street): l N�i�'�� A" TM # Section:jy_ Block Lota_ Municipality: Watershed: Za j /r'-',- / SOIL PERCOLATION TEST DATA �/ Witnessed by: Date of Pre - soaking: l � - Date of Percolation Test: Hole No. • Ran 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 ab- a 2 n _ �o — Z 21. j... 4 5 1 2 3 4 1 2 3 4 5 1 . 2 3 4 5 . Notes: Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < I thin for 1-30 min/inch, < 2 min for 3 1-60 min/inch), All data to be submitted for review. Depth measurements to be made from top of hole. Form DD -97, pg I of''- SITE LOCATION MAILING ADDRESS r•: 1 V PUI'NAM COUNTY HEALTH DEPARTMENr DIVISION OF ENVIRONMENTAL HEALTH SERVICES I PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR I--�. PHONE PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE 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 from licensed professional engineer or registered architect. Proposal` approved Inspector's Signature & Title Proposal Disapproved ronosal awroved 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 canponents tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. (e.g. #house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. IP S: W to (RED); Ye cw (Ttkin al); Pink (Appliamt) DATE i OWNER'S NAME SITE LOCATION c PUTNAM COUNTY HEALTH DEPARTMEDTP DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR PHONE TO MAILING ADDRESS'�� -,-tea tc_,.�:<� ' 'd:.�r, 111, c .'.. ? -�i'•, t <r.,•. PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY' PROPOSED INSTALLER PH('; REGISTRATION # Pro (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 from licensed professional engineer or registered architect'. Proposal approved 01 -e �� r ..�.' /4 OLS 0aw u./ Ae Inspector's Signature & Title Proposal n ,th the following conditions: � late° 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 canponents tied to two fixed points (e.g.,house corners). d. System description (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 reported agent of owner agree to the above conditions. SIGNATURE _- . c y GATE i IM: WAte (PC•D); YeUcw (Tain ED; Pink Qgiiamt) y �• • _ - o __ tl T { - .•. y f Y q 4 [ _