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Home My WebLink About0787DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -96 BOX 9 1 1 INS I I ' I ..� i Ll JNJ If i N 00787 . i PUTNAM:COIINTY DEPARTMENT OEHEALTH ... Division of Environmental Health Services, Carmel, N :Y 10512';. J Eagtoeer M- Provide P.C.H D Permit t7 ' CONSTRUCTION COMPLIANCEFOR SEWAGE: DISPOSAL SYSTEM • Ta# Map Block'_ _Lot � Fonmerl Sbbdivislo l Naiii abdv; Lot N P Mailing Address Dote Permit leaned 4 . c Aaaraae Se parate':Sewerege System built by �5a Consisting of 'U Gallosi Septic Tank and �� j Water Su pplys Public Supply From Address or: ✓ private Supply Drilled byr ` `SD— Address 1 D Ballding`Type ' - �` Hae'Erosion Control Been UinpletedY Nam bei of Bed* s ' • Has`Gs ago ,Grinder Been -installed? -i.� 0 Other Regulremonte I certify that the systim'(o) as listed serving. the above premises were'oonstructed eeae_atially 'as shown the.plans of the completed'work 1 copies of which are attached)., and in accordance with the sfandards, ruYes and r' uldtio no, " tac once lithe 14 plan, and the permit iseued,by the Putnam.County Departmeni.Of Health + 1 �. .. / Certified by '.Oats P.E. � R A. a Address EJD N L'itanse No. t Any, perion occupying premises served by the above system(s) shall promptly take.wch action as nuy ,be'necessery to secure the correction of any unsanitary conditions result)iy from such :usage.' Approval ;of the i , rate `seweraps system shall become null and void as coon as a pubt;: unitary awn beeomis available•. and '.the epp►oval of 'the private'wate► supply shall "become' null and `Vold when, a put►itc,-ivate► . wpDly becomes available. Such appiotiab are sutlleet: to dification, or'change vv n, in the 'judgment of ths'Commtisione► -of Meal uch revocrtbn, modlflatton or change Is mcnw►y. �� `.. ��- e oats By Titl _ y 1. S�SA1N C�G� a WELL UUMYLETtON REPORT DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only /'�D- WELL LOCATION STREE OUR SS: wNi I TAX GRID NUMBER: WELL OWNER NAME ADDRESS: PRIVATE O PUBLIC USE OF WELL 1 - primary 2 - secondary YRESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP 0-ABANDONED ❑ BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING .p RfE PLACE EXISTING SUPPLY ®TEST /OBSERVATION []ADDITIONAL SUPPLY W SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH /9015- ft. STATIC WATER LEVEL ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH —ft MATERIALS: STEEL O PLASTIC 0 OTHER LENGTH BELOW GRADE _�— ft. JOINTS: O WELDED dfTHREADED . O OTHER DIAMETER __ in. SEAL: O CEMENT GROUT O BENTONITE IdOTHER WEIGHT PER FOOT lb./ft. DRIVE SHOE MES ONO I LINER: IJYES IVINO SCREEN DETAILS DIAMETER (in) SL07 SIZE LENGTH (ft) DE TU SCREEN DEVELOPED? FIRST ONO GRAVEL PACK VOHOU GRAVEL SIZE: DIAM R OF PACK In. TOP DEPTH fL BOTTa t DEM ft. WELL YIELD TEST ' If detailed pumping METHOD: O PUMPED 1 tests were done is in- COMPRESSED AIR , ` ormation attached? ❑ BAILED O OTHER ❑ YES 0 NO if more detailed formation descriptions or sieve analyses LOG are available, please attach. DEPTH FROM SURFACE water Bear- inq We11 Oia meter FORMATION DESCRIPTION coat ft. (t. WELL DEPTH it. DURATION hr. min. DRAWOOWN It. YIELD 9Pm. Surface WATER CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAr4.. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLER NAM DATE ALBERT M. YATT & SONS, INC. �o� o� 3 ADDRESS Well Drilling SIGNATURE Fite. 7311 R. R. 2 Box 171A PrN F ;" ',(vN, NEW YORK 12563 .% NORTH AMERICAN LABORATORIES, INC. THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET THE REQUIREMENTS OF NEW YORK STATE DRINKING WATER STANDARDS. NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914- 278 -7600 / FAX 914- 278 -7754 ANALYSIS DATA SHEET TYPE: PW LOCATION: Lot 15, Courtney Lane, Big Elm Sub - division Patterson, NY REPORT TO: Ross Allan ADDRESS: 25 Byram Lake Rd. CITY, STATE, ZIP: Armonk, NY 10504 DATE COLLECTED: 11 -29 -93 TIME COLLECTED: 1:05 PM COLLECTED.BY: Ross Alan:, REPORT DATE: 12 -01 -93 LAB # 93 -6277 - SAMPLE - SOURCE : Well tank DATE ANALYSIS RESULT UNITS METHOD ANALYZED Total Coliform MF Absent /100mL SM 17 (9215D)11 -27 -93 THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET THE REQUIREMENTS OF NEW YORK STATE DRINKING WATER STANDARDS. NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914- 278 -7600 / FAX 914- 278 -7754 s ! e a'r•" Buildi g Constructed by Gnu 1k 1jAt\� iccation - Street R acipal.ity Building Type 1G-r ELLA Subdivision Name -- 1� Subdivision.Lot GUAM= OF SUBSURFACE SEWAGE DISPOSAL SYSM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has.been constructed as shcwm. on the approved plan or approved amendment* thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and ,hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to ....._.:....operate for a - period of two. years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant.of the building utilizing the system. The undersigned further agrees to accept as conclusive the detenn nation of the Director of the Division of Environmental Health Services of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this 10 day of 19g�7 f�os5 R ICvK- vn.L• Generay Contractor (Owner) - Signature Corporation Name (if Corp.) _./ XA / Me re M rev. 9/85 mk Signature . Title Corporation Name (ifr Corp.) J?. l V r o So 9 ess V 1 represent that f am wholly;ind.coinpNtely nsponsibls fL1114 design and location .of the proposed: syst•m(t) 1) that the sa rat• iew di sal s stem ct•d as shown on; tn• approves amendmsrat theio to, and in accordanq with the standards, ►u1as a regu ns o a above ddc►itKad, will be constru County 'Depertnwnt :of -Health,; and, that oe eomplation.lhareof a'-Catificete. of Construction Compliance" satisfactory to the Commissloner,ot Nalthwill be submitted ..to ils•, Depa tmik. and a written g araetee'wilt be.fuinisi d the owner, his successors, heirs or essilins by the builder, that mid bulklat will pNCe iA pod ope►atang. Condition, any <part of sikf. sins" Aispout'systim during the period of two (2) yeari gnnwdiatelyfollowing th•dat• of the tau- onto of the approiial 'of .the C itifkat•- o1 Constiuctk --t:om' is- of. t • original system or any repairs t eto; 2) that the drilled well descril" -bow well a bceted as slauwrl on tM approved Plan and that YW well.vrill.M In 1 In accordanq wHh tM `stn Ms. uN and rpu As of the Putnam County' Departinairt of health. WN Signed P.E. RA. - P lug O, 'e5 / X24 Addre Rev. 10/88 Date -s - Ucense no . RUCTION: This approval expires.two,years from the data "issued unless ... nstruction of the building has been undertaken and is O FOR'CONST for Cause or may Ile amwncw-or paoiiified whin ton Sid e/ed n•gfWy' y the Commissioner of Health. Any change or alterawit of construction new perm I 'I disposal of',domeNk �wnf[tiLy' private water supply only. . y Title DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # PA 9j WELL LOCATION /Street Address own Village City Tax Grid Number ,. ro�o�l WELL OWNER Name - At-Alw -0151t�t�kA Mailing Address tfv 6jZMP0V- t3Private 0 Public USE OP WELL T- primary 2- secondary Q RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O P LIC SUPPLY ❑ AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION M INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT r gpm /# E3 REPLACE EXISTING SUPPLY ®' NEW SUPPLY NEW DWELLING PEOPLE SERVED& /EST. OF DAILY USAGE �j�al O TEST /OBSERVATION Ll: ADDITIONAL SUPPLY L1 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN ODUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES (l NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_ Lot WATER WELL CONTRACTOR: Name p Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: NZA TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER•MAIN: -- LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED e "ON SEPARATE SHEET % ( toy (ditey T nature PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt;- (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a ma ner as not to degrade :o:r otherwise contaminate surface or groundw er. Date of Issue: 19�— �� Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable 3/89 White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller �iCJTNA. CO CJNT DEP,A.RTL�C NT •OE;' I-X)E:Ax.'I'X-X APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPQSAL;•;SYSTEM 1. Name and Address of Applicant: • � �tll ti.4 ". °i . t t 2. Name of Project: rWD 3. Location T, 4. Project Engineer: '1'1k m W. QI M40L�C -Tit- 5. Address: ��h �itfl` 1%t� IJj21J� to License Number:- Phone: 21 _ blob 6. Type of -Project: > ;: ; _.. ✓ Private /Residential Food.Service ....Co;nrnercial Apartments Institutional Mobile Home*Park Office Building: t Realty Subdivision Other (specify) - 7. Is this project subject:to State Environmental-Quality Review '(SEQR)? Type Status (Check One) Type I... Exempt ✓ Type II. Unlisted. 8. Is a Draft Environmental Impact Statement (DEIS) required? flU. 9. Has DEIS been completed`and found acceptable by Lead Agency? ...:....... rJ /A 10. Mame .of Lead Agency 1.1.,.IS••th1s.project in an area under.:the control of -local, planning, zoning, or other officials, ordinances? .......................................... ►.)d 12. If so, have plans been_*submitted to such :author sties ?...................... rJ /A 13. Has preliminary approval•been granted by such authorities? N�� Date Granted: 14. Type of Sewage Disposal*':% System Discharge. .....^ Surface water v Ground Waters 15. If surface water discharge, what is the stream class designation ?........ — :6, waters index number (surface) ........... ............................... K1 JA :7. Is project located near a public water supply system? iJ 0 8.' If yes, name of water supply W/A Distance td water supply , 9. Is project site near a public sewage collection or disposal system ?..... Q0 0. Name of sewage system Q/A Distance to sewage system I . Date observed: 7T 2 p�j 23. Name of Health Inspector: Project design flow (gallons per day) ...................................... b170 '2. \ 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. 00 26. Has fPD ir--9on been submitted to local DEC Office? om 27. Is an rl W, is project located within a designated Town or State wetla d. �'�,. ... .......... . ............................... _ —_rJd 28. Wetlan Nuffibe ..................... .............................. ►J /d 29. •Is Wet an P it uired ?.............................................. �•1�, Has app J ade to Town or Local DEC Office? .................. 0A, 30. Does pro ect require a DEC Stream Disturbance Permit? ................... fJ D 31. Is or was project site used for agricultural activity involving application . of pesticide$ to orchards or other crops, solid or hazardous waste disposal;``'.= landfilling, sludge application or industrial activity? YES or NO 00 32. Is project located - within 1;000-feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of" contamination? .....'.........YES or-NO' r NO klrl DESCRIBE: 33. Is.�there a local master plan or file with the Town or Village? _ 34. Are community water, sewer facilities planned to be developed within 15 years? UNKNo1oo 35. Are any sewage disposal areas fn excess of"15/40 slope? :...............:...::.. _ 36. Tax Hap ID Number 37. Approved Plans are to"be returned to: ................ ' Applicant }"' Engineer If the application is signed by a person other than the applicant shown in Item.1, the. application must be-accompanied by•a Letter of Authorization. Failure to comply with this provision maybe 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 stat&rents made herein are punishable as a Class A Hisda%eanor pursuant to Section 210.45 of the Pena 1 Lair. SIGNATURES & OFFICIAL TITLES: n,I'� ;`-'SAILING ADDRESS: Pi TAM COUM Y DEPARTME n OF HEALTH : DIVIS� OF ENVIRCRiERM HEALTH SERVI,. DESIGN DATA SHEET- SUBSUFACE SgqAGE DISPOSAL SYSTEM F= NO. Owner ALA ail Address ' Z E SY1?4 M Z,4 fr4 A'20- A RI'w o NI-E IVY 1p_5-of o t D R. AD Located at (Street) /V,,.. 7-Z Block S . Lot 7. 2 ,�o i, I ) (indicate nearest cross street) Municipality JU Watershed C-/?6 To SOIL PERCOLATION TEST DATA REQUI1M TO BE SU&ITI'ED WITS APPLICATICNS Date of Pre- Soaking 712 G 0 9 Date of Percolation Test L? 08 HOLE MEBER Q =. TIME PERCOLATION _. .. PEROOLATION Run `Elapse No. Time Start -Stop Min. l 9;sz /o; 2' /j;2 P S3 ; 3D 3 5 Depth to Water Frcm Water Level Ground Surface In..Inche's '`Soil Rate Start Stop Drop.In Mih /In Drop Inches Inches Inches '.I 2 /v;2. %. /�,s�_.._ . , ;30 2¢' Z.S �. _.._ :._._.: 1 / ...__.............._. 1-8.3 4 .. 1 2 3 NO'.I'ES: 1.. Tests'to,be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be suimittbi for review. 2. Depth measurements to be made from top of hole. rev. 9/85 5 NO'.I'ES: 1.. Tests'to,be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be suimittbi for review. 2. Depth measurements to be made from top of hole. rev. 9/85 TEST PIT DATA_.REQUIRED TO BE SUBMITTED, WITH,a-- nLICATION DES 15N OF SOILS MrMCERED IN M-.�.OLES DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. / ro 31 41 51 61, 91 -7 ix/4 7,E IUUUI 10 12 .131 141 INDICATE LEVEL AT- WHICH .-GROONDMTER IS ENCOUNTERED INDICATE I= To waica'wATER- I= RISES AFTER BEING ENCOUNTERED A114 DEEP HOLE OBSERVATIONS MADE BY: C, 1?1"-6 /7//7c - A/ c. a cAr DATE: - DESIGN Soil Rate Used /u/ Min/1" Drop: S.D. -Usable Area Provided No. of Bedrooms Septic Tank Capacity 2 SCE gals. Type Conic. Absorption Area Provided By 5_71 L.F. x 24" width trench r.,," OF NEW r W IL I A 01" Other OR � � Nary C. Signa Address 7_? /oR. SEAL 0. 0451x% ESSI THIS SPACE FOR USE BY HEALTH DEPARDENT ONLY: Soil Rate Approved sq.ft/gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVIC] Date,h Re: Property of 1,. Located at (T _Section_ Block�h:; °� Subdivision of 13 1 ► E /,in r Subdv. Lot # 15- Filed Map f4e;2 � Date !d - 1.-,-72_q� Gentlemen: This letter is to authorize -� w . Njl6H VL-2, a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules. or regulations as promulagated by the Commissioner of the Putnam'County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersi P.E. .r r ' i► Telephone' Very truly yours, Signed 2 1 Owner of Property Addr s Town Telephone -V- _ �� , rte" 10 1, tc _ �� , rte" 10