HomeMy WebLinkAbout0767DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
24. -1 -62
BOX 9
rm
L
16
00767
11 or
00767
` HOQS� ADDIT? r,�l 15w-,5
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT #
Located at ( -'C= 6�
Subdivision nameN fi . h ij 4ju ', UA Subd. Lot #
Date Subdivision Approved-
Owner /Applicant Name CIS L=Ukar -SC:r')
a'
Town or Village
Tax Map l Bloc c t 2
Renewal Revision
Date of Previous Approval
; B
Mailing Address �� Zip -Q�5DJ
Amount of Fee Enclosed 4-
Building Type 4 7r- To Lot Arealt.iz M..No. of Bedroomsv3 °PR9Design Flow GPD kC' CC
Fill Section Only Depth Volume
Separate Sewerage System to consist of gallon septic tank and Lff
Other Requirements:
To be constructed by 9TH t3 sev'OK's Address g- Qsll� j
Water Supply-
Public up ly F Address
- Private-Supply]) d ��, Lj' dress -
I represent that I am wholly. and completely responsible for the design and location of the proposed system(s) and that the
seepa*ate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in go a on any part of said sewage treatment system during the period of two (2) years
immediately followi of the approval of the Certificate of Construction Compliance of the original
system or any reps'
Signed: P E. R.A. Date s Efln
Address �� License #
D 810 --
APPROVED FQR his approval expires two years from the date issued unless construction of the
sewage treatmeni system has 'e n completed and inspected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new permit. Appr arge-ofl odic iiiitary sewage only.
By: Title: � `A Date: 2
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design ofessi al
Form CP -97
P r9
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
RE: Property of
LETTER OF AUTHORIZATION
Located at 15ecc�) -j
T/V "r Tax Map # Block Lot 2
Subdivision of
r
Subdivision Lot # 3 Filed Map # Date Filed
Gentlemen:
This letter is to authorize
a duly licensed Professional Engineer - or Registered Architect to apply for the required
wastewater treatment and/or water supply :permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater treatment and/or water supply systems
�5.and/or 147 of the Education Law, the Public Health
-Very truly yours,
ti
Signed:
(Owner of Property)
Mailing Address: IS50
'R-
't_�p �-�n
State Zip U State Zip CJ
Telephone: Telephone:
Form LA -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
{
APPLICATION FOR APPROVAL OF PLANS FOR
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant: r.2- -GD ,ic— di�a�
Yi�17
t—
2. Name of J ro'ect:
P
4. Design Professional:
6. Drainage Basin:
7. Tvpe of Proiect:
3. Location TN:
5. Address:
Private/Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building. Realty Subdivision Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR)?
Type Status (check one) ....................................................... Type I Exempt
Type II Unlisted
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... r4
10. Has DEIS been completed and found acceptable by Lead Agency? ............... h•� f'�
11. Name of Lead Agency f;, A
12. Is this project in an area under the control of local planning, zoning, or other.
. _..officials; ordinances? ............ ................. 5
............... ...............................
13. If so, have plans been submitted to such authorities? ........ ...............................
14. Has preliminary approval been granted by such authorities? Date granted:
15. Type of Sewage Treatment System Discharge ................. surface water groundwater
16. If surface water discharge, what is the stream class designation? .................... /°r
17. Waters index number (surface) ..... ...................................... ...............................
18. Is project located near a public water supply system? .. ...............................
19. If yes, name of water supply 1S Distance to water supply
20. Is project site near a public sewage collection or treatment system? ............. .... O
21. Name of sewage system Distance to sewage system QINC
22. Date test holes observed 23. Name of Health Inspector 5. �6 - ,
24. Project design flow (gallons per day) ................................. ...............................
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... C _
26. Has SPDES Application' been submitted to local DEC office? ......................... • /�
2.
27. Is any portion of this project located within a designated Town or State wetland?�
28. Wetlands ID Number ...... :...................................................................................
29. Is Wetlands Permit required? ..............
.................. ..............................................
Has application been made to Town or Local DEC office? ('r
30. Does project require a DEC Stream Disturbance Permit? ...........:
31. Is or was project site used for agricultural activity involving application of
pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ............................ Yes/No (i
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination. Yes/No �n
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? .........................
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? ................................ ...............................
35. Are any sewage treatment areas in excess of 15% slope? ... .............................C7
36. Tax Map ID Number .......................... ............................... Map Block Z-- Lot 2.9
37. Approved plans are to be returned to ..... Applicant_ Design Professional
NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall
be sent to the Department, and need not -he sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval by the Department. Projects within the watershed may also
require DEP review and approval of other aspects of a project, such as stormwaterylans or the creation of
impervious. surfaces, and the project applicant should obtain the appropriate forms for such activities from
DEP and submit those forms to DEP for review and approval.
If the application is signed by a person other than the applicant shown in Item .l :,the application must
be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision
may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this form is true
to the best of my knowledge and belief. False statements made herein are punishable as
a ,Class A misdemeanor pursuant to Section n. . 5 of the Penal L
SIGNATURES & OFFICIAL TITLES. C—
Mailing Addre:6D. �,111-1V ... ! A;E 5uwy/j 0C
�?l S'1i1, -IV31l lilies
i . jA 0 g2,
in��ll� llcl
0 -/�1TJ
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner Address T204A1 F , �^TTgV,30
Located at (Street) k—t 164 We-'2,2.. Tax Map Block '�- Lot
(indicate nearest cross street)
Municipality T:p) Drainage Basin
SOIL PERCOLATION TEST DATA
Date of Pre - soaking Date of Percolation Test
Hole No.
Run No.
Time
Start - Stop
Ela se Time
Min.)
Didth to Water
)From Ground
Surface (Inches)
Start Stop
Water
Level
Dropp In
Indies
Percolation
Rate
Min/Inch
j
1
0 3a
a C)
�� I
3
Iu
2
30 ��
av
io
3
60 0
.3o
14 -' /2. 1`7`12.
3
ID
4
5
6 2ro
3
20
Zv
5
4
5
1
2
Ilse
10
3
4
1 71
NOTES: 1. .' Tests to. be.,repeated at same depth until approximately equal percolation rates are obtamea at eacn
'. .percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 in All data to be
; *Subm'itted for review.
Depth measurements to be made from top of hole.
Form DD -97
DEPTH
G.L.
0.5'
1.0'
1.5'
2.0'
2.5'
3.0'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
2.
TEST. PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO.
HOLE NO.
8.0' 9 ova
8.5' WA
9.0'
9.5'
10.0'
HOLE NO.
r
8.0' 9 ova
8.5' WA
9.0'
9.5'
10.0'
HOLE NO.
Indicate level at which groundwater is encountered 7
Indicate level at which mottling is observed > `7
Indicate level to which water level rises after being encountered
Deep hole observations made by:, —sC SSj p4 C , jE� Q)P&,,DI) ate 9
Design Professional Name: C
Address: 10 2— A
Signa
10INK11
—=�
Lei
Indicate level at which groundwater is encountered 7
Indicate level at which mottling is observed > `7
Indicate level to which water level rises after being encountered
Deep hole observations made by:, —sC SSj p4 C , jE� Q)P&,,DI) ate 9
Design Professional Name: C
Address: 10 2— A
Signa
10INK11
i
f�
- ZUD �Ol !I�tPh,F- -. �THO tAS.A:4vucErrr_. _ _- _ARCHrrECT
79 AUSTIN RD. MAHOPAC.N.Y.10541
- (914}-828 -7495
of Z
- ice
ep -"
0
IIGY�I
r or
I
7
Ft
i
a
THAN COUNTY DEPARTNOrNT OF IMALTH
PLANS APPROVED PO L
)M COUNT ONLY; / ;
sure & Title ;+/ aTG /
�z
'THOMAS A. NUCEN7 ARCHITECT
79 AUSTIN RD. MAH OpAC,M,Y. 10541
(914)-628 -7495
P�PoyGP PDDI'rIoIJ � Pl.Tr--P,--rIDIJ -ro TNe
i
t. '
I.
II
I I �
II
IIAr
J--- MEWAW9 OF OLD 1NAMLED MAY M
Or
i
\\ o
og W 04
0000101
\ ti 9,
r PDDL E *60
P $ A,d. Ate. \\
Q - ( /'
34mr my OF fXIST74r0 \ 7
0
.&IJ- 09•lew *ad
.&4- II-ZIM ALM
9
O*6`
Ol
\ d� o°
1s, ,
'L r0
1 1
u� �
y
� � a
3�
l
i
kourrE 164
PATTER SON
Do
''iqm d-Aw mmme -rAikrw rt_li
C-T=r
A-2 =272' D-T=W
E - F= 32"
A -4 =3(':
B-1=3W
B-2"-33LW
B-3=29-S
B -4 =26.6'
C E
FENCED AREA
53,
IDL DILYWELL Pff
3W
2(Y
3(r
23'
yy �
4-n-02
O
PVC MOMBRENTS
0 B
PLT NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONWWAL HEALTH SERVICES /
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME 7. eF^s Oil PHONE k42 2 .
SITE LOCATION n�(}- �,c,�C C, Z6 y TO
MAILING ADDRESS
PERSON INTERVIEWED PC HD Camplaint .
Name & Relationship (i.e, owner, tenant, etc.)
DATE V11 f o z TYPE FACILITY
--f
PROPOSED INSTALLER T_�a i/ S'T S°4s t 1�� r . c PH=
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 fram licensed professional engineer or
registered architect.
JAA c 4-n // h e.Al ,S 17fz / -1 `0 /J v o r -f, --,� 111,%4
WJ-7,a ,
Proposal approved
Proposal Disapproved
ronosal aooroved 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,
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 owner agree to the above conditions.
SIGNATURE TITLE
DATE
_.
OOP1�'S: V to ODD); Yellow (fin ED; Pink QgJ1icant)
k
Q
i ter• •• Z $ :I �• i�
OWNIIt' S NAME i �i�� 'V° ''�5 d '7 PHONE
rc-as9 -ifl
SITE LOCATION T f l �� }'L er S TO
MAILING ADDRESS
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INST y it Na Z/ PHONE 2 77
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 lel
31.
inspector's
Proposal Disapproved
cate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed ccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam.
drywells surrounded by one foot + gravel).
e. Installer's name and number.
System repair to be perfonned in accordance with the above proposal and conditions.
I, as owner, or repqrted ag of er agree to the above conditions.
SIGNATURE TITLE _I� DATE
PM: V&te (PCHD); Yellow (awn ED; Pink (AVplimnt)
x 6' deep
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
97
'7>41
OWNER'S NAME 14f, e " 1'Yt 8,rSA ii PHONE
SITE LOCATION (I, P,,�±f:eaa:-bk1 710
n ( p I
MAILING ADDRESS AAAA A J2 V knQ- 7
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY �y
PROPOSED INSTALLER i PHA 9 L
REGISTRATION # CkL U . F,
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
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 (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 re rted agent of owner agree to the above conditions.
SIGNATURE G TITLE DATE.. YI-JZYI
IPM: %litre (POD); Ye11aw (99rn BD; Pink (AFpli,®r:t.)