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HomeMy WebLinkAbout1001DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.47 -1 -25.1 BOX 10 01001 Is i r r 41 J t1, T i�! Lr qr Is IN ` .� �J 01001 Rev 3 Located at T6*n or Village A f T. Map Block _Lot Owner/appllean; t Name J 02 r- r It J—V V—f-/-N I N rm-eWy. Subdivision Name 'gubdv. Lot # Mailing Addr .. ZIP Date Permit issued PATT r-10 :i Separate Sewerage .System built by 605FP4 —Address-4�fFwiM 22,NEFWr—A11-2FJ1--; Consisting of '1000 Gallon Septic Tank and F• A Water Supply: . Public Supply From Address or:-4/1 Private Supply Drilled by W I L I - 191211—WISU-4 JEW t Address 0 A V Building Type re-7F,--GJ1J26Ur1AL,—Has Erosion Control Been Completed? "(1 -49 Number of Bedroom@ ✓ Has Garbage Grinder Been Installed? Other Requirements I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plarA of t c pleted work copies of which are attached)_and in accorda. nce with the standards, rules and ations, in accofdance winthe filed oan,,,t t permit issued by the Putnam County Department Of Health. Date Cortif led by. aentA—� P.E. --L R.A. 7 L Address '?'� rAfgrle'112 V9, 1-211115-1 50d,141 1 b Li ..No. ej�104 V Any person occupying promises served by,th I o 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 sewers" system shall become null and void as soon as 'a pubt% sanitary "war becomes available and the a - pproval of the private 'water, supply shall become null and void when a public water supply becomes evailabhL Such approvals are subject to modification or change when, In . the judgment of the Commissioner of Mealth, such revocation, modification or change Is necessary. Date ze)- B Title io FA lam► �C�I. a - - WELL I;UMYLh'11UN N-LrUml O Office Use Only � - STREET AOURESS: WN /VIL 1 1 Y T G 10 NUMB ` -&- 7C9 Z,41,0 WELL LOCATION ,V I' , i a, , BREWSTER - LABORATORIES - Box 224 - BREWSTER, N.Y. (914) 279 -4945 - WATER ANALYSIS REPORT - SAMPLE NO. 7175 NEW WELL SOURCE: Lorraine Braun Tivoli Rd. Patterson N.Y. 12563 COLLECTED: 12-8-88 ..BY: Mill Drilling, Inc. i BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method 0 pet 100 ml. This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. 12 -11 -88 Thomas Meyer Director i. PUTNAM COUN'T'Y DEPARTKENr OF HEALTH _ SIOi3 OF ]�OAL HEALTH 62 Owner or Purchaser of Building Section Block Lot L0arZA)61 �0 Building Constructed by T N O W 00A2 Location - Street Municipality J?_ IflrnITIALI Building Type Subdivision Name Subdivision Lot # GUARANTM OF SUBSURFACE SEWAGE DISPOSAL SYSTEM 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 shown 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 determination of the Director of the Division of Environinental 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 day of A QI21 L 19� <L i 2 General Contractor (Owner) - Signature Corporation Name (if Corp.) WL • rev. 9/85 mk C Signature, Title Corporation Name (if Corp.) &(3 ,,", .I N 4" *0 a-t44 Address J F� T- Lq 6G IA ✓1 /M lot Ur a CR LOT n_ .C-.r'„ Z� ICCa -- a5 ��T cTJLQVC^' Dl�nc sc- i cr, - Da �_ ci p1acan=__ - 2:1 barr -ler Ll^� w:J`rH XTC -_DFm^ C- Ma==all sci r_ct s — c� d_ S�--ne, bry =, re c = =—= tLn 13 f =an Sus ae= e- 100 f f_ =. Nat= ccur == A --- I a_r�= _ - a. c `'_C i=-1:ti _ ° "'_ - l ,000 1,2fO 7' CrL lof CL 450 hand e_ L_ 1 .All CL =i °_ -- a_ = `T = =Tc- - - ar L_ Cr - C" sc-i - _:vc =� CCn a _ � = --17-TT -- i'._�l - - - -- I - I I i —I 3.33 L_ -_`� ;-���= 333 4. 5. C' C .c C= CC=—^i ° i ! 6 - -1/32 C. 10 GO �- - ZCL.. .C'S 7. C= < 30 -r -3/- Size cf c = -;E IG L cf c r -:� in tr`_cz L" utz. w-a I 11. Pima E.Q S_Ze C t: -::i. G= -.er L . c v e_r =! C-.V t_ „t I A P-L=- e= s' _I a - r, — =. c! L� Ci= 'c 6. C'ic-le w.- -==__= be Esz- -_Cri cer c'r C_e I a. Ecuse 4 _ WE, —L. aE : r accrue_ cl =_„� I b- D = =- .c_ f_� SD_ a=_ rr == _ f t C. C: = =-TIC 18” Zt--'ic c_ a inside ci bpi ( . d__ 1P. to — - _ C== G_ =rC:= aWa—i i=ron S14 __- I - I I i —I 1(5-M- wow _ r r ti lev• /87 1 Lf d� -e , tq� Area 1 . D.00 _ S °3 BtIRd1aQ Tm FM Sectbn.OWY Depth Volame,: Nuanber of Bedrooms: Design Flow G P ' D 6 6 PCHD Ned ad= Is Required When FM Is obmpletid Separate Sewerage System to oensW of GaRm Sept& Took �nfi �. �UDO �. �. F ar Off. Ytt�li To W cessfncted by 111 r rt Address . Water Sdppb•t Pailte Si>tpply':Ftrooi Address an Pelvttte; Supply Dr10ed`by Other ReQa4etnenta 1 represent that 1 am wholly and boinpletely respohsible for the design and location of the proposed system(s): 1) that the separate sewage disposal system above described will beconstructed as shown On't "he approved' amendment there to and. in accordance with the standards, rules all ►egY la l:= O e Y nam County Department ,of. Meelth, and that on completionihereof- "Certificate - of Construction Compliance" satisfactory. to -the Commissions of Healthwill M submitted to the Department "and •`a wri_ttan quararitea will Oe furnishetl the owner, fiis successors; heirs. or assigns by the bulldei, that slid Quilder will place in good operating condition any: part of ,said sewage disposal system during the period of two (2) years immetliately following thedate of the issu- ance of the approval of the Certificate :of Construction Compliance of :the o►iginal.systern or any repairs thereto; 2) that the drilled well described, above will be located as spawn on the ipproved;plan sa .and that klaivell, will.be Inst 11 in accordance: with the s< ardsAr ule and regu aTirons of" the Putnam County Department Of Health. � / Date a (. ��%� Signed t�.d/Lt P.E. 1— R.A. Address ! f'1 4 License No APPROVED FOR CONSTRUCTION: This approval expires two-year$; from the date - issued unless construction of the building has been undertaken a /d is revocable for cause or rnay'be amended or modified whin considered necessary by the Commissioner of Health. Any change or alteration of construction requires a new 'permit. Approved forr disposal of domestic- sanitavy sewage,, rivate w r su ply only. IS – °/ .. Title MI e DEPARTMENT OF HEALTH Division of Environmental Health Services :OUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # LOCATION Street Address Tivoli Road Town Village City Tax Putnam Lake, Patterson, NY Grid Number WELL OWNER Name Lorraine Braun, Address Lake Shore Drive, Patterson, NY private O Public USE OF . WELL 1 - primary 2 -. secondary RESIDENTIAL (3 BUSINESS O INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 FARM ❑ TEST /OBSERVATION O INSTITUTIONAL (:)STAND-BY 0 ABANDONED ❑ OTHER (specify] 17 AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED3'to 5 /EST. OF DAILY USAGE gal REASON FOR DRILLING )UNEW SUPPLY New Dwelling PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR DRILLING No public supply,avallable. WELL TYPE XODRILLED DRIVEN ®DUG ® GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES XX NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: n a Lot No. WATER WELL CONTRACTOR: Name MILL DRILLING, INC. Address: Putnam Avenue BrE 9509 IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES XX aQ ,-T NO NAME OF PUBLIC WATER SUPPLY: n/a TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN : _ - "` "' -" _ ' ._ _' _ . _ °.... • . _.. _..._._�. n/a LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED []ON REAR OF THIS APPLICATION TIE. S T ° 12/9/88 1 (date) (signature) Robert: M. :Mill, President 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 thirty (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 requirements of the Putnam County Health Department attached to this permit.. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue: �—�%' 19 Date of Expiration: 19 Permit Issuing Official Permit is Non - Transferrable DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL p PCHD PERMIT 4/—��, WELL LOCATION S reet Address I NOW �-� Town Village City Tax ��, o� z5Zr(v` Grid Number *702 ilo 41ob WELL OWNER Name Mailing auSCMA-+ 1,00AIQt Oft4M Address ` k -. ? -LT 2.064 % J'Private Y• O Public USE OF WELL primary 2- secondary .URESIDENTIAL ❑PUBLIC SUPPLY OAIR /COND /HEAT PUMP O BUSINESS 0 FARM O TEST /OBSERVATION O INDUSTRIAL 0 INSTITUTIONAL O STAND -BY ❑ABANDONED O OTHER (specify Q AMOUNT OF USE YIELD SOUGHT s= gpm /# PEOPLE SERVED '3-5 /EST. OF DAILY USAGE 0,C) gal REASON FOR DRILLING MrNEW SUPPLY O REPLACE EXISTING SUPPLY OPROVIDE ADDITIONAL SUPPLY O DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR DRILLING New CesipaKe WELL TYPE ®DRILLED DRIVEN aDUG GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name ��`� �. Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES x NO NAME OF PUBLIC WATER SUPPLY: WA TOWN /VIL /CITY DISTANCE -TO `PROPERTY 'FROM NEAREST 'WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED []ON REAR OF THIS APPLICATION ON SEP RAT SHEE j3-2-1-e-7 ......._ (date) gna ure 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 thirty (30) days of the completion of water well construction, the applicant s.hall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form.provided by the Putna County Health Departme tom.. Date of Issue: � 19 � Date of Expirati 19 ermit Issue f. Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner nrnnat- rtnryv- WAI 1 nr; 1 1 cr- 0 (UUN.UZ L&:KU<11.1t.N ' Ur' H -"i L= - 1J.LVLJ1\J1-' yr J1+Ctiv1\ INDIVIDUAL VM= SUPPLY & SUBSURFACE SEA DISPOSAL SYSTEMS s' GG' Name of Owner) COUNTS REVIEW SHEET - CONSTRUCTION PERMIT LF trenca provided required 60 ft. max. Parellel to contours DATE REVIEWED: ` (Street -Location.)--- _ .. YES I NO I DOCUMENTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth Plans - Two sets permit; PWS ce Request s/s SUBDIVISION Perc (3) Fill _- cd letter GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Pe* -mit Same REQUIRED DEZAIIS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D r Box;Trench /Gallery; Pump'.pit details Se zc Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data: perc and deep results Two -Foot Contours Existing & Proposed Driveway & Slopes Q t �G tter�Cur -_ - rains* (discharge OK) Perc _. Deep Holes 7 _... _..._ . _ ............. Rec_ sentative c : -_ _� a and expansion flow,suff. size Pi L- & _ hewn & Detailed Hcuse - No. of B_c wells SSDS's w /ir. ft. of Proposed Systems Prope_ _v Metes & Hcu2 -etback Neczs_ ;Tight lot) �-wer - +,'= J — 110; Ty7ce pipe ON PL.2_ -- -to P.L. , Drlv ewayr Large Trees;'Ic.: .o Fou: da--' ,,a *' s . i;' to Well; r�" 1P_ D. L. _ to Stra =m, ';�,a r� , �,--L 4ke Co catch bas_n,3-�c —,,dr'aln,pl -`EQ NC == -= =s� 10' to Water Line (pits -201) 5u' intermittent drainage course Sentic Tanks 10' from Foundation; 50' to well 15' Well to PL Q 10 APPENDIX B PUT'NAM COUN'T'Y DEPARTMENT OF HEALTH - DIVISION OF HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEin%M DISPOSAL SYSTEMS W51 REVIEW SHEET - CONSTRUCTION PERMIT required 60 ft. max. Parellel to contours FILL SYSTI .S claybarrier 10 ft. fill notes new spec. depth cauces 100 yr. hood elev. _... DAT _B �o d 44Z BY: (Street Location) YES NO DOCUMUS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) oe Deep Hole Log Consistent Perc Results ol Peso Hole Depth W.0 Dit _ J .ar�Yr s/s SUBDIVISION Perc (3) Fill cd letter GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Pen-nit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) �Hdraulic Profile - Gra vity Flaw imensions - Volume h /Gallery; Pmnp pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder notes) Design Data: perc and deep results Two - Foot ^Contours Existing &Proposed Driveway & Slopes Cut Footing /Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff, size If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms � ells & SSDS's Win 2.00 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 1'0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTZ�_N'CFS SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Tcp of fill 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' frown Foundation; 50' to well 15' Well to PL E DESIGN DATA SHEET- SUBSUFACE S30M DISPOSAL SYSTEM FIB NO, Owner Address l• Located at (Street) I (\j I Sec: ' c52 Block G, _ Lot - (indicate nearest cross street) Municipality Watershed"iC?c`i SOIL PERCOLATION TEST DATA RDQUIPM TO BE SUMMED WITH APPLICATIONS Date of Pre - Soaking - - PTJ Date of Percolation Test _ _ Z7- &7 HOLE - - NCMM CL= TIME PERCOLATION PERCOLATION Run Elapses Depth to Water Frccq .. Water Level' No.. Time - Ground Surface i In Inches Soil Rate Start-Stop Mina _ Start Stop.` Drop In Min/Sn Drop Inches Inches Inches 17 - 2 4' ZH — 24- 3 I('- t6 -10' -4S :3O- 2 rZ% 4 3cl Z7 3 En, 3 IU••Oi 5 , 1 3 4 i t Tests to be repeated' at same depth until approximately soil rates are cbtained.at each percolation test hole. All data to bbe.submittmd. ``. __ for review.; `'2. ' Depth measurements' to be made fran top of hole. Y44 �x I yrr I K 171 t2t%iNGli 10 lo w C, -r I a 0 PIox, (T,-f fl.) A5-DUILT .r rC/ALlC,: 1"= !Wi Av - V U i t,-T NJ A v 1 t7 -11.0 oo-o, 61.0/ -15-01 t7 2v 0, (,q.0' -n. .-..I I -o I -q 0" Co 1. � 4+ 5, 5V. o' "tl 49 10 Ol fl TH112 [�'1-0 one- -r1 F%" -rHie"T THE. ,J NA90, M7 101,0A-ret2 ON -rR it ? rLA N AN t2 THAT IT Mb MWIZ-e IT WAS C10Ve4?-bl2 aV� M. TH � V-(�TCW WA,9 ot)NE TIZUoTbO IN AOOOKOANC& ►IT4 Of WUNT-f t2er^fz-TMrN-T Or Hf�ALTH 4 THE N✓N -fOF-K-- TA-Tfi p�PAi?l`tyi ANT OF H�ALrH. NoTrl,? HOU,57f'i L,/XA-Tl ON TAKEN r-FZOM "T00061A,AIPHIOAL, 1 1. fr-0Z Joy trH A Lag-fe-AW� IMAUN, VA-TI?X9 V-f FZoVeKT H. WeoL-L,