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HomeMy WebLinkAbout0902DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.39 -1 -11 BOX 10 00902 kWT, ` X11. r Q-� ��� �r 00902 �, .n town or Village Located at „ 0 w t°j �'V 0 � Tax Map - Block . /� —� p__ Owner ,C� ye i t3° . �iC S%1 1'%9 3�3 �`2 b Tax map jr of # % ' �i�% uw. # Separate Sewerage System built by & A �w Su ��t Zk AA Address J (��" / \ ��5�/�` VC .,1410 � Consisting of Gal. Septic Tank and 4ef+ YI d.Q-G'rf� cklg6,i Other requirements Water Supply: Public Supply From Private Supply Drilled BY ' Address Building. Type���� +«1 -t'tJ No. of.Bedrooms-3— Date Permit Issued J�• ��1 Has Erosion Control Been Completed? I certify that the syetem(s) as listed_ serving the above premises were constructed essentially as shown on the plans of the completed work.( copies of which'are attached);, and in accordance with the standards, rules and,regulations, in accordance with the filed plan, and the permit issued by the Putnam County Departibent' Of Health. "`�'° // .A Date �� ��` Certified b y P.E. '" R. �A6 ZJ Addregl�e°�Qye 3.�eerG 1�c�_p 6 Via! -�y�s 4IV ° .7. License No. Any person occupying premises served by the .above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate nivfdrage system; shall become null and void-as soon as a public sanitary sewer becomes available and the approval of °the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in .the 'judgment of the Commissioner of Health, such cation, modification or change Is necessary. Date / °— By Title~ 0 I I II Owner or Purchaser or Building AM�t 71 M-l"IdIng Constructed'by L _5 �/ V I,, go ac� Location - Street 'Building Type -T Ph ffe Municipality Section I Block 7.S Lot ....GUARANTY OF SEPARATE SEWAGE-SYSTEM I represent that -I.am wholly and co.mpletely..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 shown on the.approved plan or approved and in accordance with the standards, rules and regulations of , the Putnam County Department of Health and,.he,jr.eby'guaranty to the owner.; his,succes- sors, heirs or assigns., . to place in good operating condition any part of said system constructed by mie'which.fa.ils.to.operate for a pe'riod of two years immediat . ely following the da:te or'.'initial use of the sewage . disposal system., or any'repairs,made by me .to such system., except where the failure to operate properly is"ca*used*.by the*,willful or negligent act.of the occu... P of the building utilizing the sly's t 6m.. The undersigned further Agrees to accept as conclusive. the de-. termination of the.Director.of the Division of Environmental Health Ser- f. I 4-k 4- 1� to ♦wh ther or nc P . 4-1, an 14-,.o . ..L V11 P".­ , -Co Hoc4a. %j'L U U failure of the system to operat e was A caused by the.willful or negligent act of the occupant of the building utilizing the s Dated this 177 day of 1 19 Signature oGe'*� T.itl e p za W&rsd-c If corporatioft, give nEu, and address) - - - - - - - - - - - - - - - - -- - - - - - - - - - THREE (3) COPIES ARE RE QUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Division of Environmental Health Services, Putnam County Department of.Health JUN - 3 7.982 RUIFNAM C(- DEP'r. OF HEA"IT19 WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by well driller and submittgd to Cofinty Health' Department together with laboratory report of analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NAME ADDRESS LOCATION OF WELL o. & Street) // (Town) (Lot Number) (� II �JF�'� G- PROPOSED USE OF WELL BUSINESS DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL 11 SUPP Y ❑ INDUSTRIAL ❑ CONDITIONING OTHER DRILLING EQUIPMENT COMPRESSED F—,f L-c"LE ER ❑ ROTARY ❑ AIR PERCUSSION = PERCUSSION ❑ O(Specify) CASING DETAILS LENGTH ( feet) 3 0 DIAMETER (inches) 69 7/7 T PER FOOT THREADED ❑ WELDED R O YES ❑ NO C Gj 7 YES LJ NO YIELD TEST BAILED ❑PUMPED ❑COMPRESSED AIR HOURS G.P.M. 17- YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE — STATIC(Specify feet) DURING YIELD TEST le@t) j 1 Depth of Completed Well in feet below land surface: SCREEN DETAILS MAKE LENGTH OPEN TO AQUIFER (feet) SLOT Z 7R (in e IF GRAVEL PACKED: Diameter of well including gravel pack (Inches): G (Inch FROM DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. FEET to FEET f�� i'' y: „.: ,•,1 ,, : -_ y9 DEPT. - s If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL MPLET D DATE:7 R ORT ,y 6.— WELL DRILLER (Signature) T / YMRKTOWN MEDICAL LABORATORY INC P.O. Box 99 321 Street Yorktown A \ iMts, N.Y. 10598 LOCATIONS: O 3,n nsAnST, Yonsrowm *s/a*rs N.Y. 10598 245-3203 ' O 201 BUTTONWOOD Avs,rssKusILL,m.v' 105*6 737-8777 ' O w wor��T�msoorw�+1os*e- s�azxo-'-- - mcLsmn AVE. (NEAR *onp/TA4oAnMsL,m.Y. 10512 ' oro*ono oATsTAKsw � DATE soevso '--��-- o�rs SAMPLE SOURCE: nspsnneoSv: L- -J COLLECTED BI LABORATORY REPORT / 4� mo/L - OAc/o/r/ ... []ALUMINUM ............................................................... []ANTIMONY ..--.-.----.--_.-,____.____ ~�� []�nusw/c �N�eAoTsn/x`ToTA�/m� .................................. E3 ..^^.^---.--- ......................................... '�feoo.soAv_-_.-_..-.--.-----.----._--- []BARIUM _^,------....--.-.-.-.'----------' []BROMIDE ............................................................ []BERYLLIUM ............................................................... [] CARBON DIOXIDE, FREE ....................................... []BISMUTH -._--_..---------.-.------- []CHLORIDE ............................................................ Oaonow -----.---_-----.-....-_.-.--.-~... Oo*Lon/ms ........................................................... C1 CADMIUM -.----._--.-.-------_.....-'- []coo ---..-.--_-....".....-.-----.....-' OCALCIUM .....---''-------~~----~~^-^-^~-' 1:1 COLOR ............................................................... [] CHROMIUM (totl ........................................................... ~ C3CYANIDE ........................................................... [] CHROMIUM (hmmo, lent) ................................................... O DETERGENT, ANIONIC ............................................ []COBALT ^.--.-----_----._.-..-'--.--^---- OFLuonms............................................................ C1 COPPER --_--.-.-.--.---....--...---.~--' I] HARDNESS ........................................................... []GOLD -----_.----.-.-.- .--. '-.-_.- 100 ml ............................... []/nom .......................... K��' - ��'------'-- 2=0 �ounm ��..-..-----.-.. []�e�m ._--..------..�'�--_.-~~.'---^--'~- [] CONFIRMATORY TEST _........................................... O Lnrmum ---.--- ................................................. ................. ...,....____ O NITROGEN, xusLoA*L............................................ []MANGANESE ............................................................... O NITROGEN, NITRATE ........................................... 11 MERCURY ---..------��J����J�.'��)�iQ���--.-.. O NITROGEN, ORGANIC ...---------...-.---.,' []w/oKsL ....-..-.-.-.-.. -f-.1 .-m ---- []ODOR ............. ,T -. -.._.--. [pxLLAcxmw ............................................................... Oou& GREASE ....................................................... []poTA$a/mw ............................................................... 0 p -...---._--.---_-.--------..--..- []RHODIUM -._---..---_---.-----.-----.' [] PHENOL -.-.---.-_--'._-----.--.----..�....... []SELENIUM ----'.-.---.-.---_-.--.-.---.- [] PHOSPHATE (ort»o ) ............................................ C3 SILICON --_..-.----__--.-_--.---.----- O PHOSPHATE <rv"uo"seu>........................................... []SILVER .------.-----------_-.-.-.-----^- [] PHOSPHATE (total) ...... [] uoo/um --_-----.--.--------.--_--_--- _ ' [] SOLIDS, SETTLEABLE, mVL ................................... []TIN ----_---_-..-..-------.-----.-.- [] SOLIDS. SUSPENDED -....-...--.-..r.-...--.- []ZINC --.---.----....--.-'-.---------^'' [] SOLIDS, DISSOLVED ..-..-..,-_-...- ......... [] ........... .................... ................................................... [] SOLIDS, TOTAL ..................................................... [] ....-...-.....,........^..,..........^^.^..�.' []uouD�VOLATILE -.---------_---.--.._ [] REMARKS: -..---_`----.---.----..-'----' [] SPECIFIC CONDUCTANCE ........................................ [].................................................................................... OouLpATs............................................................ [] ..----.--.....-..-.....---..--..--.-.---... []SULFIDE ............................................................ [] ..---..-.-....-,......--..-..---..'.-..~..-' OouLFITE............................................................ [] ..-...,.........-.-..................`........-_.,,. OSunFACTANTS ............ ....._......,.........�� -[].................................................................................... ` 0 TVR$|0|TY ..................... , ................... ............... []................................................................................... T8DG8 RESULTS INDICATE THAT THE W&T8R�WAS 'OF & SATISFACTORY SANITARY QUALITY WHEN THE SAMPLE WAS COLLECTED.' . U THESE RESULTS INDICATE THAT THE WATER DID MEET THE SATISFACTO Y CHEMICAL QUALITY OF NEW YORK STATE ADMINISTRATIVE DDLDG & B8GD ^,n�n� q VxnnI/xNTr m Ir /unrP\ 1)TnPn70n,� !lam `/d Lr3v. Fee I' A� 6�, ter. M /N /M ✓M. E! LP yTC KED AMP CQILOOtiIEP io F?REVErt.1T 14+E 9. Rr MOVt* ALL TR£ES YWI' 41iJ 10 ACy,E OF keAV`/. EGaJWMeQT ctid TAI v `A.R5A:. /O•No 9E". e ,SYSTENLS .:OIJ AdEIC' 'i�,rr7 -TEa7 1Y' 7 s PBSIC�.1 &W&,r,lEER AND TWC- ; FV71J,&" OF a�?OPo5Et� WELL.',, LrCGSpT d •Th-r�T AFTE -R iur�?ALLAi10r.J AUD Molt Tb 04C-14FILL • 11. WO WELLS 'OrJ FtEICaH901a1t1C� IUM 54FE 1f1 LP OF 5 g..p• rn - I �xPrtc �`.7T£:M, 5 t3A4✓ED c" -Nrz LGL'ATaG�t.l CAF THE 5ewAcael 5�(STEM, 12, -1NENVrzti FrZ?r✓( i FOOT P>ELOW .- wl-Ks, , POADS 4k.10 VRIt/EWA`(5 Sg .�iHON/At 70 THC- AM2ot�D L 5iT.OMtWG;uS. Mt,Ttrf� lAL 7O qt ly lal2E TO HAVE F12101z Pcr117 . APPRONAI .. INJ THS SI:F'ric "MLiv-, GA>,JO Ca kGG �✓E prle v > C cA7ED AAJO �4Rr A✓ CA D%N 6L.G"+A WA Y t3. ;�tQ F'l F2T `(' 5+{ W N :I IJGI -U _ 7 r,,I- CtYAK6e .OF sTORA4 N /A7ei< Q{g , TIAEW VSO 1. M OF f"'U7'NAt�A L aA-V- ' (MAP '1VE gatilrTAl2� WAdj7E�i O.JL� 7Fd`Uf�GlJAl2G�E AU t oL�►.lCja 7. TDF RAST ',✓173 4WATEi O eeWj-1A1& WA7100- 02 07-PF_ e O &LE,T�2fOU5 � OA/72a 7F16 Sc�RG.asGt: OG Tf�'£s.C.aaoclAt/J /5' t�20/•f /8 /TED. i . i 7f/g ,Qt(oNj' OG /.IISPe,::. p 9IJ,OF THE FREM- /.5C /Z . - W /TTd THL3E k�'fj�Ui�EMEA/7'zj. l6 57RU .TLrRE /5 PE/ZM /T7�t.7 UtitTt(:. '�E GaVSTRc- +G7ia�1 ?7CW rrA-, BED XPEF60I va P AM-7 pP/ ,apVC-.� 4y Z ;7HC- 5y5TEM, THE. 5S 0-5, 49VA Z5,gAL.L &F- co✓5k2 -o WY 7W 79• GNES 0, M)R 5,91z-, SegDt 4 W17N A M1,<rO V ep.V72kWi)L1& :4 PA2T�a c1P P;~REx/nt /AL R '/5 caQASS AA1O 'C'OMP4AIEO f 6�. xA*5, 4T 711E XATL of -f fJc%AIOS PEtz I,OG3� CV'%, FT. Ar7rZ ' ! ./ 5r�4w MULCrt g,+ocL LiE dPPtrEO 'T7 7X16 56-6060 I I • f !lam `/d Lr3v. Fee I' A� 6�, ter. M /N /M ✓M. N' gT.G7F,TilE. L°F?AG� - rREWC-14E5 f� Rlt((a momFzri.ES W1TId.IrJ 2� FL6sT i l'WPEiZT1ES WITN1AJ .2470.E -6ET OF PROR?r�U THa LiawtD 'pt�{D'aL3O /6. Tb PEE C.OATEP WIV4 t'ar!'1"��'f'T�+E'�GbrJ'G.rZETE FaoM G�ET��IO2ATtaly f 1 t•aE'''.i72QP' ': PUMP :P /T WNEAJ APPLIGA(aLS) . �' ti0'T. I1c�5:'.41A�"�I'1S AG,,�tl�VifN G►.i "OrIXr� . #�'q'�Er) 1.4 IC ti:1tM±1T1 ©N'.•T�.tC�.�L•n hV�YB'+r f�i s•.CIIIbI A lzeO." j c. ' ":�' • R, E.V,I SIGNS- `, .a: _... No DESC41P,LIOM;;;. . I A B s K D ,.. -Z, 7 123 .._.. . E _ t7 6 Z 4. � 79• Z ! l f 6�. 74 ' I I • f I .. i N' gT.G7F,TilE. L°F?AG� - rREWC-14E5 f� Rlt((a momFzri.ES W1TId.IrJ 2� FL6sT i l'WPEiZT1ES WITN1AJ .2470.E -6ET OF PROR?r�U THa LiawtD 'pt�{D'aL3O /6. Tb PEE C.OATEP WIV4 t'ar!'1"��'f'T�+E'�GbrJ'G.rZETE FaoM G�ET��IO2ATtaly f 1 t•aE'''.i72QP' ': PUMP :P /T WNEAJ APPLIGA(aLS) . �' ti0'T. I1c�5:'.41A�"�I'1S AG,,�tl�VifN G►.i "OrIXr� . #�'q'�Er) 1.4 IC ti:1tM±1T1 ©N'.•T�.tC�.�L•n hV�YB'+r f�i s•.CIIIbI A lzeO." j c. ' ":�' • R, E.V,I SIGNS- `, .a: _... No DESC41P,LIOM;;;. . I !,1 G 2�'s}?JE^•118.12',. `.51VeTAO "e; -IA:04' i • .. � •` � i /' ` X31' '•�`/ �// " J `1 / R4 I' r '( •Putnam County De tment'of Health` l r ° `• Division %of'Environmental Health sdrOioes Approved as .noted for conformance With kaoJecr applicable r: s Qnd Regulations of ;the PROPOSED RELP Tutu Count alth L'e i tar itle Date N, Y `r'1 �R�o New c?e f �: GAfi.4CJt`1; tAi °, AtJVKF -W MAN. • , � ; / :: I 8 � \�(�i - • _ l� Fi i�ilvtaA6.E ,,A1�t:F] 2 v .. • ' u ia��P • � 35 ae .�^ RAN ©�Lf V t ` T - 1 / :. . • �• � �� 'E iY AZ\ - •DQ�.N�9UR1 MAO Roams i {I w � ol>l - j f: - � N CONSl;1LTi�fG f tc;a �ww : Gco c j` SEWAGE OISPO Sip solLL IZ4M: 'k Mim, - V1 �. a>?Fw.-ATiorJ t�rkTE = I.2�Pp /�F I Aw°. 1?t�JFIUt.I AMA 'rte.: ' : i .(OC'�Li. FQ " 1 ..2 io•f �j �F s {1y, % ' - Q . �'�0' D tW'N , !t.001�at 'rA0'.' F DEePTH = le.0 L;F# I I , I r 0 Square Feet., i the proposed,system ( s); the- s6parate -se wage,. disposal system I .in accordance with the stantlards', -rules and ;regu ations of = e Putnam instruction Compliance 'satisfactory to the Commissioner_ot'Health'w�ll Nner, .his successor's; heirs or,aisigns by;ahe 6uilder, that Mid builder will I the •period of two '(2)_years immediately follow;ing.thedatb;of the.issu- sl` system or any repairs - •thereto, 2j_that;fhe drilled well described above an' cgrd, .,c wdh the stan r s, rule's, and ;regu a`ons - of ttie Putnam c icense No issued unless construction` of fhe building has been undertaken ahtl is ie` Commissioner ,of Health. Any :change., or alteration of construction r'i_priv e` w er. supply =only % Title �(/ NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM- ❑ industrial (Specify) ING TREATMENT WORK i p Other (Specify) INT OF DISCHARGE Surface Water: (Name of Watercourse) r. (Name of Watercourse to whic Class .:4 water is tributary) I Class 11. IS STATE OR FEDER� APPLIED FORT �� .. L' Z rj`f¢L'lL�i NL% i/rL."6000 /Jae`' -NG/x. O Yes No LO�C?A�TIIrON( City, Village, Town) TYPE OF PERMIT PERMIT NO. DATE ISSUED Give Project No. jam'/!' I c���/�;�" ❑ NPDES ❑ SPDES /�j ' AV 12. NAME OF DESIGN ENGINEER NEW YOR STATE LICENSE NO. ADDRESS I TELEPHONE NO. 13. WATER CONSUMPTION (GPD) Present Future Design Year 14. POPULATION SERVED Present I Future Design Year 15. AVERAGE DAILY FLOW FOR NEW OR EXISTING TREATMENT WORKS (GPD) Present Future Design Year I�trz) -� 16. SOURCE OF WATER SUPPLY (If private well; give location, type, depth and character of soil) 17. DESIGN. EQUIVALENT POPULATION (BOD Basis) __ .... _ 7�'iC?/ �! l . Gig l�% Lill C.tJG�+�70 /l' �✓f7fZ? ,'A� oa auk sign flow C Design Plant Efficiency L& D L P /I r� /2% W f � GPD Ip 18. GIVE NUMBER, CHARACTER AND DISTANCE OF ANY BUILDINGS WHICH MAY BE AFFECTED BY THE 19. DESCRIBE PROPOSED OR EXISTING STORM WATER PROPOSED TREATMENT WORKS DISPOSAL �J /% `I. /J1E S7�ZCtciil�c «'mss //J� /L�Ccr0 w't' rllV& 01?WiAoW ADDITIONAL INFORMATION MUST BE SUBMITTED FOR PRIVATE AND INSTITUTIONAL SYSTEMS. 20. INDICATE OF U.S.G.S. TOPOGRAPHIC MAP EXACT LOCATION OF SEWAGE TREATMENT WORKS AND ADJACENT BUILDINGS. SHOW LOCATION OF ALL WELLS OR OTHER SOURCES OF WATER SUPPLY WITHIN 200' OF THE PROPOSED WORKS. GIVE DESCRIPTION OF THESE SOURCES AND CHARACTER OF SOIL. t0;6,5, &W pu Icy -1 T�Si per IJf7 d 21. STATE DEPTH BELOW EXISTING GROUND SURFACE 22. DESCRIBE SOIL AT SITE OF PROPOSED WORKS. GIVE DESIGN BASIS AND OBSERVED SOIL PERCOLATION AT WHICH GROUND WATER IS ENCOUNTERED RATE DATA (Use additional sheet, if necessary) T€57- j nmr /Cv r eetwECEIVED /v oml:- &v,—,'e r6iz DEC 8 1981 DATE: /lJ 92 -19-0 (12/76) Formerly BSP -5 PUTNAM COUNTY 1:--NAME-OF APPLICANT �- - - 2. LOCATION OF-WORKS (C` oy, Village, Town)- 3 C OUNTY =- -- 4. ENTITY OR AREA SERVED 5. TYPE OF OWNERSHIP ❑ Commercial ❑ Private - Other Institutional ❑ Authority ❑ Interstate Federal ❑ international O Municipal . O Sewage Works Corp. ❑ Private - ❑ ❑ Industrial WPrivate - Home ❑ Board of Education ❑ State ❑ Indian Reservation 6. TYPE AND NATURE OF CONSTRUCTION ESTIMATED COST OF CONSTRUCTION Collection System Treatment and /or Disposal Collection System Treatment and /or Disposal 14-New '❑ Additions or Alterations ew_, 1 /0 Additions or Alterations 17. ❑ industrial (Specify) ING TREATMENT WORK i p Other (Specify) INT OF DISCHARGE Surface Water: (Name of Watercourse) r. (Name of Watercourse to whic Class .:4 water is tributary) I Class 11. IS STATE OR FEDER� APPLIED FORT �� .. L' Z rj`f¢L'lL�i NL% i/rL."6000 /Jae`' -NG/x. O Yes No LO�C?A�TIIrON( City, Village, Town) TYPE OF PERMIT PERMIT NO. DATE ISSUED Give Project No. jam'/!' I c���/�;�" ❑ NPDES ❑ SPDES /�j ' AV 12. NAME OF DESIGN ENGINEER NEW YOR STATE LICENSE NO. ADDRESS I TELEPHONE NO. 13. WATER CONSUMPTION (GPD) Present Future Design Year 14. POPULATION SERVED Present I Future Design Year 15. AVERAGE DAILY FLOW FOR NEW OR EXISTING TREATMENT WORKS (GPD) Present Future Design Year I�trz) -� 16. SOURCE OF WATER SUPPLY (If private well; give location, type, depth and character of soil) 17. DESIGN. EQUIVALENT POPULATION (BOD Basis) __ .... _ 7�'iC?/ �! l . Gig l�% Lill C.tJG�+�70 /l' �✓f7fZ? ,'A� oa auk sign flow C Design Plant Efficiency L& D L P /I r� /2% W f � GPD Ip 18. GIVE NUMBER, CHARACTER AND DISTANCE OF ANY BUILDINGS WHICH MAY BE AFFECTED BY THE 19. DESCRIBE PROPOSED OR EXISTING STORM WATER PROPOSED TREATMENT WORKS DISPOSAL �J /% `I. /J1E S7�ZCtciil�c «'mss //J� /L�Ccr0 w't' rllV& 01?WiAoW ADDITIONAL INFORMATION MUST BE SUBMITTED FOR PRIVATE AND INSTITUTIONAL SYSTEMS. 20. INDICATE OF U.S.G.S. TOPOGRAPHIC MAP EXACT LOCATION OF SEWAGE TREATMENT WORKS AND ADJACENT BUILDINGS. SHOW LOCATION OF ALL WELLS OR OTHER SOURCES OF WATER SUPPLY WITHIN 200' OF THE PROPOSED WORKS. GIVE DESCRIPTION OF THESE SOURCES AND CHARACTER OF SOIL. t0;6,5, &W pu Icy -1 T�Si per IJf7 d 21. STATE DEPTH BELOW EXISTING GROUND SURFACE 22. DESCRIBE SOIL AT SITE OF PROPOSED WORKS. GIVE DESIGN BASIS AND OBSERVED SOIL PERCOLATION AT WHICH GROUND WATER IS ENCOUNTERED RATE DATA (Use additional sheet, if necessary) T€57- j nmr /Cv r eetwECEIVED /v oml:- &v,—,'e r6iz DEC 8 1981 DATE: /lJ 92 -19-0 (12/76) Formerly BSP -5 PUTNAM COUNTY NOTE: All applications must be accompanied by plans, specifications and completed Form BSP-65 (appropriate portions). The submission must conform to a previously.. approved engineering report describing the system in detail. The plans must, be stamped. with the_ designing _engineer.'s_ sea l_and.must be-of sufficient clarity.and eligibility to permit satisfactory microfilming. Only white prints will be accepted because of the difficulty of microfilming blue prints. There. must be a blank area, at least 4" x 7 ", in the lower right corner of each sheet so that the approval stamp may be placed on the face of the plans. Any deviation from the Department's standards for wastewater collection and treatment facilities must be explai.ned in detail. 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 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 210.45 of the Penal Law. Signatures and Official Titles KEMAKKS: Mailing Address: a4_,- _5"11z� Date of Application: PUTNAM COUNTY DEPARTMENT OF. HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDIN3,_CARMEt, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner Mnef,%L �1 Address ; 1���/J-!l Located at (Street I01 V@GV`ec . Block Loth AID -41 IS kindica e nearest cross s ree Municipality. >- Aj Watershed &/,y SOIL PERCOLATION TEST DATA REQUIRED'TO BE SUBMITTEDWITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Run apse Depth to Water Water Level. No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in , Min. /in drop Inches Inches Inches I 1 —1117 2 I1-0- 11-V8 560 2 3 4 2 3 too' 5 1 - 3 4 DEC .81981 5 PUTNAM COUNTY - - DEPT. ot RMTH Notes: 1) rates are for review 2 Tests to be repeated at same depth until approximately equal soil obtained at each percolation test hole. All data to be submitted Depth measurements to be made from top of hole. DEPTH 6" 12" .18" 24" 30,; 36" 42"1 :.4g!1 5411 60" TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. I HOLE NO. �'� HOLE NO.. ..ter Er 721 78" INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED LEL TO E� S � AFTER BEING ENCO TER�, , W FVINDICATE B Date DESIGN - Soil Rate Used -'� NLirVi Drop: S.D. Usable Area Provided.,�. No..of Bedrooms Septic Tank Capacity Gals. Type. 24C, Absorption Area Pro By ____–=__ L.F.x24" — wed h..t�renc Name ; l )wm Yve i,,Aw &m7– z5ignature r Address mil/ SEAL C) r 4 1-I rr, oy i THIS SPACE FOR USE BY HEALTH``DEPARTMENT ONLY: ..0 IV e4 51!s Soil Rate Approved Sq`; Ft /Gal, Checked by .tea_._ �te x P UMA M COUNTY DEPARTMENT OF HEALTH g : Division of: Enw�onmenta) Health 5erwces, Came% N Y .10512 CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM. n Patterson Towrt ort magiL _ Locatetl at T y� -� R Ca� {R F Section = Block s Putnam Lake, 41172 5 & 4149 -57 I`ac1 yob SO.131 -5 Subdrvislon Owner Gregg Cdhi11 "� Address 50 Cameron Road Build ing'lype Frame 'Ae r Lot Area - Putnam .!Lake,: NY 1.0509 { Number, of Bedrooms Three _ r ' Total Habitable Space 1024` Square Feet 000r. 36 inch ; Separate- Sewerage System to consist of ,Gal Septic Tank 4y lineal feet X 3 widths trench Al s r x To be constructed by 'Address v _ -Water Supply }Public Supply F om - _ X x r w Private Supply toibe drilled by a v Address - - Other Requirements Fi 11 Sects On 36'll peep x _50 x 9' 4 s a ^ - aral6.=era. �Gs� i$iALB.o':.C`abolA jai �pye .�o:a�e.� a: b. �Q>rc °,.Cp .,1, .' p4i;(�ji t:c'�..tj�dd /)7 C�e�l represent that °f am wholly and completely responsible iorahe,tlesign and to on? ,of ; t o gpropd6e sy em sj; '1) ;that the aeparate se age. disposal.3system s- ,r ;above desoribed,`will be constructed -as shown on the`approyed amendment there to and; ln accordance•with the tandards;r:rules an regu a- ons.o e u nam. -' County Department o .. Health, and that on completion thereof a 'Cettificate of *Construction Compliancet'' satisfactory to the Cortim ssioner of Healthwill be submitted to�the Department,`and a written guarantee will be furnished the; owner, his uceessdrs; heirs "or assigns by the - builder, that said builder will place en ,good .operating condttton" any part of s5id 'sewage disposal systerr► during_ahe peitod `of two (2) years immediately followingahe datwof" the issu- - D ance of� approval of- :the aCertiftcate of Construction 'Compliance ofi ,the original'system , or "n - ,00patrs fl ereto 2), ;that the druied.;"w described :above .1N " -=_� ��_ - — _ ill be located as♦own on_the approved plan and °that said' well will be tnsf led iri' •accordance; with - andards, rules and regu a; only of ''the Put?iani County; pepartment of .Health ` Date'-' i 6 Sept 1973 f_ Sign t air p E X ;R A D�. 29206 `" a�' = "' ^ `Address R • Q . 6"' R+OX 3 %' C �+ .z,.. s'3 •LlCensa No - "4- APPROVED FOR - CONSTRUCTION Thar- approval "expires =one romthe date issued 'unless Cohstructidn ofFthe'DAiding..has been undertaken and is '< E revocable for :cause or; may be amended oc modified whentconsitleced necessary by.' the Commissioner of Health 'Any than ,or. alteration of eonstrucfion regwre ew. perBmfd A( /ply ®yproved for disposal of domestic itar sewag a pnvate _water wpply only f �� `r �N ELA]r 'Date y x ' Title 0 PUTNAM COUNTY DEPARTMENT OF HEALTH a DIVISION OF ENVIRONMENTAL - HEALTH SERVICES - - - COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner `gl2t11- Address 'yn�i' Located at ( reet f1fl., i e ep Sec.' dock Lot Indicate nearest cross street) Municipality. py -te„ Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH. APPLICATIONS Hole Number CLOCK TIME PERCOLATION. PERCOLATION apse No. Time Start -Stop Min. Depth to Water From Ground Surface Start Stop Inches. Inches Water.Levei in.Inches Drop in Inches Soil'RAte Mixn,/in drop . 2 3 5 2 4 5 Notes: 1) TbAts,to be repeated at same rates are obtained at each percolation for review. .2) Depth measurements to be made depth until apppproximately equal soil test hole. All data to be submitted from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO.- HOLE NO.. G.L. 6„ 12" 18" �; � ►,g 2411 30„ 36„ 42" ��►�� 4811 5411 60" 6611 72„ 78„ _ 8411 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED Al®1-@ INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING E COUNTERED �c - TESTS MADE BY ��) �f�9� /� A_Date gtfiT B �ry Soil Rate Used__`-- 0Min/1 "Dr0p: L~ �f S. D. Usable Area Provided /0000 No. of Bedrooms 2&wq Septic Tank Capacity /®®® Gals. Type nro4pq Absorption Area Provided By _L.F.x24" " e! width trench. Other Name e ; n H. Prentiss, P E, 6 Signatu Address R.D. , BOX 353 �QFESSIO e N �. F Camel-, New York 1051 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Che G� b )T)) Date o. 2970 E �� ®� tHE SINII � k.. 4 ` .fit• '.�� � i. r /. / � � . w � / e Y a ,Zz'`r• F• Mo 90AD S01'i. KATE.: '4'm I W. ,. 1 . AP