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HomeMy WebLinkAbout1188DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.62 -1 -48 BOX 12 m 9 is r I .r ELI - T , 71 � � ,, , r f . , . , ., ... �. - . PUTNAM COI7NTY DEPARTMENT OF HEALTH ` ReV 86 I)ivieion of Envtronmentsl Health Serytces, Carmel), N Y 10512,.'1 P[OVlde�. / 4 •7 , d y� F a t, i a9 i�s "p #. Y (��• t p':r t r a �, " ,,. s -.1 Pit D Permit N� a t "� CER ATE QF;CONSTRUGTION`COrvIPLIANCE FOR SEWAGE DISPOSAL SYSTEM fi 4: .$ F o or,VWa�' ;Located it ° f? 0 • ? t O l9 a K az Map ADD Btock Lot �3 A icy / V ('�NwGT O� Formed - Sabdlpleton Nome SDbdy Lot q .Owner /appHceat Name a y _ , a w * ll-�o ,u 1� 1 zlP P. , Malling Address 1 s %a �. Date Penmlt Dad r l- .m rq/ n - �' S t..- m . jl t —7 F ✓f'�J� N ;Separate Sewerage Syeterii built by r 5 er�sAdldreles'/ se tie /� q L �61 �N Consisting of - Gallon p Tank andd / Tk' -des ,1 1::,w i Supply Ppbllc Supply From ' 1' } ?'�lddrese �/ or: ° V V' private Supply DrWed rby �� ��1- Address �e�+ dQX �!���� t7 " BDud1n /1-E5� D�Tlil9�- Has Eioslon Control Been �CotnpletedY B: YP :Number of,lBedtoome _` F " ` Hae'Gerbage, i der Been Ins IledY s, ! �%iJ at I' Other`Regniremente ' •Z certify that tha systems) as listed serving the above premises were constructed essentially as- •shown on ehe,pTana of the completed work'( copies of which are attached) _ihnd in `accordance with ttie standards rules and iegulationa dn' accordance with ttie filed' plan .and the permit "'iseued,by the (>utnam County D pertment.Of Health Date % Certified by t ` PE: R7,Ap. t Addreu 73 f/9 /Zy/�L17 /N 1 I� J 7 Licence No " ✓ / O I Any person occupytny premises served by, the 16ove systems) shelf promptly take wch actbn _as may be nepsspy to aeuri the correct lon ;of any unsanitary conditions resulting from, wch ufage `Approval ,of the.- separate siwsraye >jrstem (hall become null,atnd void is soon as :a putt(; satnitary aw* r`pecomes avallibla and: -'t he" of the'`private "water supply shallrbecomes`null` , .1 -.void when a public ,water wpplY bpconies: avaiNble, Such 'approvals are sub)ect ,to modif,iptlon or change when' •in the Judgment of the Commisslonpr of Health fuch revocation;.,modlfieptlon or cMnpe Is necessary. Title 1 ��. _::.ram- �.�..�n..:.r-- ,.,,��A: �, :.,.W.: ,-.. e„_ y., r. IIxT eeamrc::x�v;em��ms�arsr'i�..•RY .- . .. W I. 11.. -:' PUTNAM COUN`T'Y DEPART OF HEALTH DIVISION" OF ENVIRONMERML -HEALTH SERVICES Owner or Purchaser of Building Section Block Lot 1.) Building Constructed by Location - Street (.2P Municipality Building Type Subdivision Dame Subdivision Lot # GUARANM 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" fbr 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. Da,t,ed this day of -&t-4 . 1909-9 i �� C4 , � -L General Contractor (Owner) - Signature Corporation Name (if Corp.) �-� E r Address rev. 9/85 mk Signatur X7�z4jjlf e j Title do� VV- x 1 �t. WL'LL- 1,V11rLG11V1V Rl_.t'VAl J� DEPARTMENT OF HEALTH r Division Of Environmental 'Health'; Services =- �W PUTNAM COUNTY DEPARTMENT OF HEALTH Office use 'Only - WELL LOCATIONfa STREET AOURESS: WNlvl 1 Y TAX GRID NUMBER: e U I WELL OWNER NAME: ADDRESS: PBIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 -'secondary YRESIDENTIA L 0 PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED O BUSINESS ❑ FARM O� TEST/ OBSERVATION O OTHER (specify), ❑ INDUSTRIAL ❑ INSTITUTIONAL O. STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE ' SQ gal. REASON FOR DRILLING NEW SUPPLY D PROVIDE ADDITIONAL SUPPLY ❑TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTIN G DEPTH DATA WELL DEPTH S ft. ' -WELL STATIC WATER LEVEL - v ft. DATE MEASURED DRILLING ' EQUIPMENT O ROTARY. COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING 1/0' PEN HOLE IN BEDROCK . ❑OTHER TOTAL LENGTH o2 ft MATERIALS: 9STEEL O PLASTIC O OTHER CASING LENGTH.BELOW GRADE ft. JOINTS: O WELDED THREADED O OTHER DETAILS DIAMETER' 7 in. SEAL: ❑CEMENT GROUT II(SENTONITE'OOTHER WEIGHT PER FOOT —/! lb./ft.. DRIVE SHOE YES ONO I LINER:OYES VINO SCREEN DETAILS ' DIAMETER (in) SLOT SIZE LENGTH. (ft) DEPTH TO SCREEN (f t) DEVELOPED? FIRST ... 0 YES o No HOURS SECOND - GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH . ft- BOTTOM DEPTH It. WELL YIELD TEST If detailed pumping I MP00: ❑ PUMPED i tests were done is in -, 19COMP AIR , formation attached? O BAILED ❑ OTHER ❑ YES. O NO y�IELL LOG •lf�more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing well DIa- �eter ­ ' 1 FORMATION 'DESCRIPTION CODE• ft. ft. WELL DE It. DURATION hr. min. DRAWOOWN ft. YIELD 0M. Lan ce o2 s77 iaC C1 CX . 6_�(] K, WATER CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ •COLORED ' ANALYZED? , OYES, ONO ANALYSIS ATTACHED? O YES, O NO � STORAGE TANK :,,TYPE /6 CAPACITY. aG h ,,, GAL. PUMP INFORMATION / 1/ TYPE ��.���'.� � c • CAPACITY MAKER �r� �,� DTn .0 DEPTH Q U MODEL �" G' VOLTAGEi30HP WELL DRILLER NAME DATE IS M. HYATT & SONS, INC. Well Drilling SlGtiitTURE Rte. 3.11 R.R. 2 1 Box 171A N NEW YORK 12563. CA. 006,766 own -2Y eae Street /88 1 ?nm PC Date Taken �+�19 TI, Y keodvn Deights, � _Y._fl0598 -, (944) 24S -320 -ata Reported: APR. 221988 Director: Albert H. Padovan X T (ASCP) Coglected By. 7 R erred By:. T J..V. CONSTRUCTION le ho ation: HARMONY RD, yS�a OOre Ed. PATTERSON, NY. 12563 U U.cl Ou 115 Phone # Sample Type: L Repeat Test ? - _ (check one) X LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER_ GENERAL BACTERIA X Standard Plate-Count (CFU /1.OmL) (Agar Plate @ 35 °C) MEMBRANE FILTRATION TECHNIQUE (MFT) X Total Coliform (CFU /100.mL) Fecal Coliform (CFU /100mL) Fecal Streptococcus (CFU /1OOmW MOST PROBABLE NUMBER TECHNIQUE (MPN) Total Coli-form: MPN Index (per 100mL) Fecal Coliform: MPN Index (per 100mL) OTHER ANALYSES REMARKS (For,Laboratory Use) .3 _ Potable _ Non - potable _ STP - INF - _ STP EFF Other: Sample Status: (check each) Outgoing _ Na2S203 Incoming X LE 4 °C GT 4 °C KEY FOR TERMINOLOGY RDS = Recommend Disinfec- tion of Source TNTC= Too Numerous To Count CON = Confluent ( =TNTC) LE = Less Than or Equal to GT = Greater Than N/A = Not Applicable THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN °T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH NE ORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. ,,Albert H. ?adovan II. IV. V. vi. FINAL SITE - INSPECTION Date r P . :;CATION OWNER' Inspect by ko%v 100, # TM # OR SUBDIVISION .LOT # - - - - . -COMMIMS - SEWAGE DISPOSAL AREA a. SDS area located as per approved plans b. Fill section - Date of placement 2:1 barrier. LGTH WID'T'H AVG.DPTH c. Natural soil not stripped d. Stone, brush, etc., greater than 15' fran SDS area. e. 100 ft. fran water course /wetlands. SEWAGE DISPOSAL SYSTEM a. Septic tank size 1,0 1,250 b. Septic tank instal level 4 01 c. 10'- - minimum fran foundation d. No 900 bends, cleanout within 10 ft. of 45° bend e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested 2. Protected; below frost 3. Minimum 2 ft. original soil between box and trenches f. JUNCTION BOX -- ro 1 set g. TRENCHES 1. Length required -- Length installed 2. Distance to watercourse measured - ;ft. 3. Installed according to plan 4. Distance center to center. C. 5. Slope of trench acceptable 1/16 = 1/32 " /foot. 6. 10 feet fran property line - 20 feet - foundations 7. Depth of trench < 30 inches fran surface 8. Roan allowed for expansion,. 50% 9.:.Size.of gravel 3/4 - 1 " diameter 107 De th.of gravel in trench 12" minimum 00 4 11: Pi ends capped h. PUMP OR.DOSE SYSTEMS 1. Size ,of chatbP 2. Overflow tank 3. Alarm; visual /audio' 4. PLunp easily accessible manhole to rade- 5. First box baffled 6. Cycle witnessed by Health Department estimated'flow cycle HOUSE � � a. House located per approved plans. b. Nmter. of bedroans • WELL a. Well located as per cipproved plans b: Distance from SDS area measured ft. ` c. sin 18" above grade. d. Surface drainage around well acce table. OVERALL WORKMASHIP' , a. Boxes properly grouted b. All pipes partially backf illed c. All pipes flush with inside of box d. Backf ill material contains stones < 4" in :diameter e. Curtain drain installed according to planj f. Curtain drain outfall protected & dir.to exist.watercours 9. Footing drains discharge away ran SDS area h. Surface water Protection adequate i. Errosion controi provided on slopes greater than 15 %. DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL,.N.:Y. 10512,(914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL • PCHn PF.RMTT $ WELL; LOCATION .. Street Address ; ��CAr►�vR� 1��7 Village City Tax � Grid Number WELL OWNER Name . '. C7 Mail ' ng Address ,, �. V f2�� .'Private O Public SE OF, WELL - primary 2 - secondary 'RESIDENTIAL 0 BUSINESS 13 INDUSTRIAL 0PUBLIC SUPPLY. QAIR /COND /HEAT PUMP O FARM 'O TEST /OBSERVATION C3INSTITUTIONAL ❑ STAND -BY OABANDONED 0 OTHER (specify O AMOUNT ,OF USE YIELD SOUGHT _ gpm /# PEOPLE SERVED 3— /EST. OF DAILY USAGE_450 gal REASON FOR .- -DRILLING . NEW SUPPLY OREPLACE EXISTING SUPPLY .O PROVIDE ADDITIONAL SUPPLY O DEEPEN EXISTING WELL ❑TEST OBSERVATION DETAILED REASON FOR DRILLING Jew WELL TYPE E[DRILLED DRIVEN DUG QGRAVEL D OTHER IS WELL SITE SUBJECT TO FLOODING? YES _X 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 _ C NO NAME OF PUBLIC WATER SUPPLY: N J� TOWN /VIL /CITY ... DISTANCE TO +PROPERTY ' FROM NEAREST WATER MAIN: ... ,.: ,.........__ - _... ...... . .�;i .% ... _ .... -. _ ..... _. .._._ . ___.._ ............. - - - -... ...... _ . F LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED bo /0 2.41'/4 .. ON REAR OF THIS APPLICATION &;,�ON SEPARAU SHEE (date) signature) , 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_3 / ��- Date of Expiration--00, xpiratio 19 ermit ssuing c a Permit is Non - Transferrable White copy: H.D. File 2/87 Yellow Copy: Pink Copy: Orancie oopv: � 0 0 =tom ii=0 4 Owner Well Dri11Pr APPENDIX PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENM HEALTH SERVICES INDIVIDUAL WATER SUPPLY SUBSURFACE a, OG DISPOSAL y REVIEin] SHEET_." -_ CONSTRUCTION-' PERMIT DATE REVIEMM: BY: Location) I DOCUMENTS .- Permit Application Corporate Resolution Plans - Three sets s/s Engineers Authorization Design Data Sheet (DDS) SUBDIVISION Deep Hole Log Perc Consistent Perc Results (3) Fill Perc Hole Depth cd Tans - Two sets - permit; PWS letter Variance Request GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots'Checked and (Town/DEC Permit R & D)' Data On DDS Plans & Permit Same REQUIRED DETAIES ON PLANS Sewage System.Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow '�1 Prof ile & Dimensions - Volume D o JJ ;Trench /Gallery; Pimp pit details Septic Tank - Size, Detail. Well Detail, Service Line if over Construction Notes (grinder notes) _.Design Data: perc - land -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;shownogravity flow,suff. size If Pm ped Pit & D Box Shown & Detailed House - No. of Bedroams Wells & SSDS °s w /in 200 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /411/ft. 4 110; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 101 to P.L., Driveway, Large Trees,Top of fill 201 to Foundation Walls 100' to Well; 2001 in D.L.O.D, 1501 pits 1001 to Stream, Watercourse, Lake (inc. expan) 151 to Drains - Curtain, Leader, Footing 35 °to catch basin,stormdrain,piped watercourse Name of Owner) COMMENT'S (Street YES No IF trench provided required 60 ft. max. _ Parellel to contours `,Q t _. _... .. 1 i FILL S STEMS cla rier 10 ft. fill notes new . d i 2:u aes 100 yra flood elev. '101 to Water Line (pits -201) 50' intermittent drainage course bPeptic Tanks ran Foundation; 50' to well 151 Well to PL ' ' la 4 PtTI'i M ' CO M� DEPAR OF 'HEALTH DIVISION OF HEALTH SERVICES :. DESIGN DATA SHEf�SUBSUFACE _SPMG9 DISPOSAL SYSTEM _ _. . owner t2V L =TI= address } ZM©0 Y l�D. } I��h'l C '' C)t� � 1J Located at (Street) �`fchMOQ I Sec: (00 Block . 3 Lot 7�3• -A �96 (indicate nearest' cross street) rmnicipality Watershed C.-fLOTO l� 5031 PERCOLATION TEST DATA RDQC= TO BE SUBMiTrED WITH APPLICATIONS Date' of Pre - Soaking Date of Percolation Test -(&&-7 _... SOLE NOMM CLACK TIME -- PERCOLATION _PERCOLATION Run Elapse! Depth-to Water.From Water Level: No. Time Ground Surface In Inches Soil Rate ...Start Stop Mn Start 'Stop Drop In Min/In ]Drop Inches Inches Inches 2 I Ol I I '• lo' 3 i ',2,0 _4- 27 3 3 j(9 %'32-• 10'. 73 2, '1-9 I Z7 3 7,0 4 5 1 0, 5q 3 (n,3 - 2 11, Iq - ((' 3' j ' W 27 (At-7 3 114 - t 2= o f 10 24 27 3 5 t. 2 i 4 r 5 7 NOTES: 1. Tests .to be' repeated at same depth until,apprcaimately equal soil rates are - obtained .at each percolation test hole. All data to' be. submitte d for review...;., Depth• measu�remehts' to be made -from top of hole. wv+id'A;k,r " " >a :...•. .:•y.... .. .. .. � .T'..'.. 'r. :`'.:�. .. � .. � .- 5,ta.4., .. :.� ^.�.a4".��ta.:�,.L1 i G.L. 2° . 3° 4° 51 ... 6° 70 80 9° 11° 12° TEST PIT DATA HOLE .NOo �...... _ _. 13° 14° INDICATE . LEVEL AT WHICH GROUNDMITER IS - ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEE, RISES AFTER BEING ENMOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: '7 2 DESIGN Soil Rate Used (�'�j Min/1° Drop: S.D. Usable Area Provided 2'340 No. of Bedroams 3 Septic Tank Capacity 1000 gals. Type (Cn1CK7�' Absorption Area Provided By ago L.F. x 24" width trench Other Name kc. I PL Signature Address �3 bA I1. -R ELD ID. (1-I yE / SEAL �, IGL�.7�lV tom{• 2� P° _ -?''. ,� W dN 'THIS SPACE ' FOR USE BY HEALTH DEPARMEM ONLY.- <ro No. 56124 Soil Rate Approved sq. ft /gal, Checked by �FESS100 to a Putnam County Department of Health Division of Environmental' Sanitation _..AFFIDAVIT.- .._CORPORA.TE. OWNER APPLICATION. _ ..:.... _._._ . . FOR PERMIT. APPLICATION SUBMITTED TO ;. PUTNAM COUNTY }IEALTH DEPARTMENT Tb: Commissioner of Health - In the matter of application.for ° I• _ — L]CI'ty, _iV.l�i'L.v �,,E',l� — /-!— — — �-- — - — represent that I am an officer or employee of 'the corporation and arm authoriied. to act for — (name of corporation) having offices at t ,11, . — — — — — — — — ..:::::_ . ._._.:..:j — — Whose officers -are President - ame cl caks -' Vice- President - - - - - - - - - - - - - *— - - ' � (N _Dme and Address) Secretary _ - - - -- — — - — — — (Name and Address) — Treasurer, (Name. and Address) — — — and that I am anti will be individually responsible for any or all, acts ; of the corporation with respect to the approval requested and all* sub- Sequent aeta.gelatin- thereto. - Sworn to before me thisay Signed-;4 of 19 �7 I Title _ I'll� — - --• N t y Riblic JOANNE M: MASH Notary Public,'State of New York Qualified in Putnam County Q Commission Expires Dee. 29, I%A.A Corporate. Seal 5MIVAN RKIvi� SCALE: f"= 30" Ag - OU11.-r DIINIr-N5ION GHAK•t NO• A 13 2 00' y2" i 5 >L' -7'q' O 7 6 ICY7" 99 q I05" 103 . I-2 X04' 95 13 72" 99' y IR' 79' 95� Ig t'�" 101' Iro 93� IDlO sppiloable H� 'utnam count; '�Qrta— tt1—o A qx q i I f PROJECT" P� nArjf sr%N CLIENT TH15 15 TO CeWTIrY THAT THE SEWAGE D19p05AL. 'v 8Y5TEM WA ' CONyTKIAGTVP Ay INDICATED ON TH15 I PLAN AND ,THAT THE SYSTEM WA5 INSPECTep 6Y ME t3C110 fC IT WA5 COVEKED OVeK. THe SYSTEM WA5 CONyTKUCTCD IN ACCOKDANCe WITH ALL STANDAKD' aULEy AND K.eGIALAT(0N'5 OI' THC MATNAM COUNTY DEP KTMCNT OF HEALTH AND THE NOW YORK STATE DOPAKTMENT OP HEALTt1, NOTE: HOU f% LOCATION 'TAKEN MOM yUICV6Y OF / MOI°EICTY— ITC-rAKED FVK J:.V.CONSTKUC -TION- DATED - - - - - -- 3- Iq -97, ICE I- fy•9S AND- PKEPAKER 151 KObep -T I DRAWING TITLE H. E•EIZGEND� IZf'P. �r NEWy . f /�( ILLIA 0451 1