The URL can be used to link to this page

Home My WebLink About0507DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 15. -1 -17 BOX 6 00507 1 I a, �cr . '` oil 1-� IL 00507 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR YES NO Internal Use Onl~ ❑ --// Repair Permit issued in last 5 years VDelegated of in Watershed ❑ l� Repair within Bo yd's Comers W. Branch or Croton Falls Res. P y ❑ ( Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review ij SITE LOCATION %'S�� s q e f a+C A � TM # OWNER'S NAME it PO aAeyf PHONE # MAILING ADDRESS APPLICANT pytnetl'� �: (�J. I? �on7v'AG> A/A5 Name & Relationship (i.e., owner, tenant, contractor) DATE a I o� FACILITY TYPE St !� a''"' PCHD COMPLAINT # �� LLw• PROPOSED INSTALLER ��`�� I�` %�7f (,� .�,.�P PHONE #fir �a0 ADDRESS -44 2.D zu) &IMQ- (,.��YZ ��% AV, REGISTRATION /LICENSE # PC 2q6 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. �r� .,t F ,`,� f�./�c�L! / %K. 5-�---- 1-41- :t ..S e-9 ;- .'H y sy�,�„y, C all Llel/ S /I r 2-19, 1�i °� StdY � % iek . l bG9st ec� 7 � 5�(t Is 1'. i a�Q Q •SVe- caYN i N 1 pe.,+ r0.1 I, as owner, or rep SIGNATURE rted agent of owner agree to the conditions stated on t is form y " /�':f✓' DATE Y PrODOsal aDDroved 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 I 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 acc rdance with the above proposal and conditions. Proposal Approved Proposal Denied CA Inspector's Signature & Ti t$ Date COPIES: White (PCHD); Yellow (Town 131); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 e i r 1 'I I, i t� a �< *0" NEU 16, 2 �r { J pgv{G.„�Jirw.: a R9 {.� � t J fi . 'S m 44, 753 SF' 1.03 ACRES (L.1 O 11, PG. 160) N 2074'04 liz r�- ,(317.66' S r0A.c. Vi v X MAPJ �Qg9s F- 01 p S 22 39'19" W 4g'f 8" W 76.10 w S 09• ecO up COM UP 1 i 1 I 15-1-20 NAP MILLER (L. 637, PG. 76) � 4 f � i f � M _ _ S ::ofd * PUTNAM COUNTY:DEPARTMENTOF �IEALTH DIVISION ;OF ENVIRONMENTAL Rig TLU SERVICES °W �j04 FIELD ACTIVITY:REPORT NAME: TPl -7 $ ° /cam 7 9 —�.-- _ ARF:SS: r Street .. Town State_ - Zip PERSON IN CHARGE Nameaan& Title :a TYPE OF`FACILITY , FINDINGS 5� �� h� /D® -Aef 4Wa� %StrV -4G�t` Gain e/ Na '� -U _ I r c - z ' S TNSPFC'T(1R:, A Signature and Title I RFPCIRT- RF:C',FT VFTy R'Y2 I acknowled le,reco ' of this report SIGNATURE; 02/96 Title. ex o k% It 4 s IV , 1 fi-TLA-6 LAAD 0,7ap it eq /of 5 :5 � ,? e 3% NAME .ADDRESS DOWNEY 149 STAGE COACH RD (erecruwl)l fe-0 11 h �y PUTNAM COUNTY DEPARTMENT OF HEALTH MISSING AS- BUILTS PERMIT TOWN` -: ` : = TAX MAP.:. :y INSTALLER APPROVAL DATE ASBUILT RCVD R- 253 -06 PATTERSON 15. =1 -17 ATLAS 10/30/2006 NO 1. SITE LOCATION V"", PLTTNAM COUNTY HEALTH DEPAR7MENT DIVISION OF ENVIRONMERM HEALTH SERVICES PHONE 7M# I9 03 MAILING ADDRESS PERSON INTERVINOW PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY Kt'S'�J rc,� i01 PROPOSED INSTXJM r) 40- PHONE 2 Z Fs - 7 S,6 S_ REGISTRATION # %OIA Primal (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 app rov Proposal Disapproved : z Inspector's ignature & Title 7//*te 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 carponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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 rted agent of owner agree to the -above conditions. SIGNATURE TITLE rc, t1J DATE 2 0 � Q .S: Wzite (MV); Yellow 03n EI); Pink (Applfa mt) PC -RP 97 CpGr AM Sheet: of * * : - PUTNAM COUNTY:�DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL IiEATLH`SERVICES, _ -w _. �•:. .: YIELD -ACTIVITY REPORT - D�.�:�`�/ Ah1)RF ' AL4 ' r State ;. Street' Town Zip PERSON IN CHARGE OR IN TFR VTFWFn Name and :Title TYPE OF .FACILIT— Y Sysc�- Y� rsno FINDINGS s e F�-cx ` P...R -• i Cjr / vl- r`T�� -:.1 , ,r , i t 9 `-( ,,,, nn ya, CC 1Y Ile�t A (t1 Q� 4 OWNER'S NAME SITE IACATION MAILING ADDRESS PER.SCN INTERVIEWED DATE ',• `•. N9 f "• � •: • a - • is •iy �a�• •+a. ..• • •. • • I ei 1 • •. a • aq• • r PHONE — LIgo PW Complaint # Name & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY j e sxo y I l i U PHONE REGISTRATION # 1 (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. _ _, __ I I n .. - A (n _ - -- i I &- /, if A t I Proposal approved ✓ Proposal Disapproved Inspector's Signature & Title 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 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, p eported ag ent. f comer agree to the above conditions. o SIGINZ M !� .!�/ r TITLE DATE 0"M4: V*Abe (PO:D); YeUc:w (fin BI); Pink (Arplicent) \ PC -RP 97 ^ 39 3 to �� / 19 I ` o 16.89 AC. 3 l397.� 20 n 1120(s) 18.28 AC. CAC 507.85 0, `21 !Z . 1.68 AC 22.78 AO 1.84 A 240.99 20.4810 �; . :.. ,/. • • .. . � 1.70 =` AC: .f 304. 1 N;y�g 30 AC. (DEED). ti i _O OP N 637.44 25 o ti 2.73 AC. 35 l 22 ' 95.11 AC. �J 26 53.,73 AC. CAL. All a`O 141 / rri .. 1 137.58 �r :) 3-5 D 41 .0 •. N 23 Q i -4 � 1.84 AC. a o 'n 1.85 •A 16 ^4.84 A� �. 4 1.44.19 :;AC. ,CAL. AC. 584.69 o ° n 9 -j c = r m .. ?:. oleo !Z . 1.68 AC 22.78 AO 1.84 A 240.99 20.4810 �; . :.. ,/. • • .. . � 1.70 =` AC: .f 304. 1 N;y�g 30 AC. (DEED). ti i _O OP N 637.44 25 o ti 2.73 AC. 35 l 22 ' 95.11 AC. �J 26 53.,73 AC. CAL. All a`O 141 / J SCP r,hk PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL ADDITION / REPAIR FORM SECTION A. GENERAL INFORMATION or Name of Project / ` " M(V) TM# l Year of Construction Size of Parcel✓ SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. 011illy ORolling CISteep slope Gentle slope Oflat 2. avidence of wetlands Clow areas subject to flooding Clod'ies of water DDrainage ditches a,, Rock outcrops 3. Property, lines evident? 4. Water courses exist on, or adjacent to parcel? YES O 5. Existing individual wells within 200ft of the existing. SSTS? SECTION C.. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM (SSTS) 1. Physical character of existing SSTS area. A. OLevel slope OSteep slope B. OWell drag �d 0M.9derately well drained ❑ drained OPoorly drained C. Area available for SSTS. (Primary. & Reserve) ClExtremely limited (3somewhat limited OAdequate i r i �r A ft • 0 f D. INSPECTION Date Inspector �— ONo evidence of failure ClEvidence. of failure ®Evidence of seasonal failure -------- - - - - -- ---------------------------------------- (Indicate North) HOUSE -------------------------- -------------- - - - - -- ---�--� (1) Indicate location of SSTS A. Size and type of septic tank ;7< gallons Metal Concrete ®Plastic B. Type of absorption area 1. Fields ft. 2. Pits Dallies ft. (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING WATER SUPPLY COMMENTS : ® Shared well In i - ual well Mrilled []Dug ®Casing above ground