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HomeMy WebLinkAbout1411DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 33. -2 -33 BOX 13 .OIL ` 9 L 'j 1 of ' La 16 IN f go . ` 4 , 01411 TRev. (((3 86 Located PUTNAM COUNTY DEPARTMENT OF HEALTIi Division of EnA-1111ental'Healdi Services, Carmel, N.Y. 10512' Engineer Must Provide p .4 P.C.H.D. Permit k, tUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEMKYfTSw. ..` -� Town or Village . Tax MeP slack —Lot �_ Owner /applicant N11oSe Formerly Subdivision Name rwil �Sabdv. Lot N L7 Mailing Address Z -7,13 5eyrnooz, 1-wo/ Zip b Date Permit �ilt issued yO�9Z j3✓L�n NY — Separate Sewerage System built by J �,,1���1 Address L A<� P9 m'�° �- A l Consisting of I Z 5 O Gallon Septic Tank and (a � t> � � Z y a� Tines C4 Writer Supply: Public Supply From Address on Private Supply Drilled by l � SON t Address 3 I lest 2 �j��c 1 71 I�i�%T Sony nA Building Typed /`Mn� Hue Eroslon Control Been Completed? Number Of Bedrooms Has Garbage Grinder Been Installed? Other Requirements 2 s 1 13 c-t S r C v112� w. d - pfe—A f H I certify that the system(s) as listed serving the abov'( premises were.constructed essentially, a shown on th plans a corn eted work ( c ies of which are attached), and in accordance'with the standards, rules and''regulations, in a the lied a an t rmit luau by the Putnam County epartm t Of Health. r Oats fi �✓ Certified by . f /� yn��� R:A. Address 0 A3 6 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 conatitions resulting from such usage. Approval of the - separate sawsrage system shall becoins null and void as soon as a pubV: sanitary f0*91' baaOmos 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 Ma lff, such revocation, modification or.change is necessary. Date / By Title S� � �-�- -j ANALYSIS DATA SHEET TYPE: PW LOCATION: Lot 17, Jennifer Lane, Patterson, NY REPORT TO: Joseph Cappelletti ADDRESS: 84 Lake Drive CITY, STATE, ZIP:Mahopac, NY 10541 DATE COLLECTED: 12 -21 -93 TIME COLLECTED: 2:30 COLLECTED BY: J. Cappelletti REPORT DATE: 12 -23 -93 LAB # : 93 -8164 SAMPLE SOURCE:_ . Well tank.. DATE ANALYSIS RESULT UNITS METHOD ANALYZED Total Coliform Absent COLILERT 12 -22 -93 THIS SAMPLE AS ECEIVED AT THI ABORATORY MET THE REQUIREMEN OF N YO, K ST TE DRINKINGWATER STANDARDS. r' a 1 t � Laboratory Director NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914- 278 -7600 / FAX 914- 278 -7754 cla:` �OAO ,j WL,LL IJVI'1rLG11V1Y ix,rvni * * DEPARTMENT OF HEALTH Bivis:Luii 'Or Er►v�ruantenta Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only Ici�i WELL LOCATION STREET AOURESS: 715WNIVILLAGAICHY TAX GRID NUMBER: tl' WELL OWNER NAME: ADDRESS: PRIVATE ro PUBLIC USE OF WELL 1 - primary 2 - secondary It RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED ❑ BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY O MOUNT OF USE YIELD SOUGHT __Is— gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE 6©0 gal. REASON FOR DRILLING pgPLACE EXISTING SUPPLY ®TEST /OBSERVATION []ADDITIONAL SUPPLY ffNEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 465 ft. I STATIC WATER LEVEL a-Z ft.1 DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY aKcomPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED O OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH _ tL MATERIALS: STEEL O PLASTIC ❑ OTHER LENGTH BELOW GRADE it. JOINTS: O WELDED THREADED ❑ PTHER DIAMETER in. SEAL: O CEMENT GROUT ❑ BENTONITE OOTH R WEIGHT PER FOOT _ Ib. /ft. DRIVE SHOE YES 0NO_j LINER: G YES afNO SCREEN DETAIL` DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEP TO SCREEN (ft) DEVELOPED? FIRST eD\YES 0 No kq qc SECOND 7 GRAVEL PACK Nos GRAVEL SIZE: IA ER PACK. In. TOP DEPTH tt. 80 aht DE h. WELL YIELD TEST If detailed pumping M HOO: O PUMPED t tests were done is in- COMPRESSED AIR t ormation attached? 0 BAILED O OTHER ; 0 YES O NO 1�lELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ino well Oia- Meter FORMATION DESCAIPfIDN CUE ft. ft. WELL DEPTH it. DURATION hr. min. DRAWOOWN ft. YIELD gFm. Land Surface © r' WATER Iff CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? YES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK : TYPE�(� _ � W / CAPACITY WELL DRILLER NAME DATE ALBERT M. HYATT, & SONS,'INC. ADDRESS Well Drilling SIGNATURE Rte. 311 R.R. 2 Box 171A . 1" S ItiE',r`, YORK 12563 PUMP IIXFOO MATION TYPE Ste' ""Wil CAPACITY _L_ MAKER N � DEPTH (, _ ' MODEL VOLTAGEiL Pb`TNAM COUNTY DEPARTMENT OF HEALTH ,. I IVYLSIUW GF° ENV1RUi�IMN i iy � c;F i,TH SEFcVICES . _ ..... Owner or Purchaser of Building Building Constructed by Location - Street FN-ff �� .�o►J Municipality 1r2Chi10 fA,TTI /'iii Building Type _"I U 1 3i Section Block Lot -rp r- ome-s Subdivision Name 17 Subdivision Lot # GUARANP= 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 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 day of 19 ` Signature Title General Contractor (COner) - Signature Sys I- L. yp t (� _ nj Corporation N (if Corp.) Address rev. 9/85 mk Corporation Name (if Corp.) Address I r ,f . DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER.^ CARMEL, _N.Y. 10512 (914) 225-0310 .__._. APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #k WELL LOCATION Street Address _� To Village City Tax /Grid Number "� h�+u 0 ( � WELL OWNER Name S7, a 1� QZ Mailing Address r , °D' Z 3 �� CK1 otg NPrivati O Public E OF WELL i - primary 2 - secondary %'RESIDENTIAL_ D BUSINESS ® INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION ® INSTITUTIONAL O STAND -BY ® ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT 6— gpm /# PEOPLE SERVED /EST. OF DAILY USAGES41 gal ® REPLACE EXISTING SUPPLY ® TEST/ OBSERVATION Cs ADDITIONAL SUPPLY WrtEW SUPPLY EW-DWELLING) ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR 'DRILLING WELL TYPE DRILLED DRIVEN []DUG O GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: T_ Lot No. WATER WELL CONTRACTOR: Name l7 -e Address: _ IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ti,�NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION KETCH SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET Cf (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. 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 manner as not to degrade or otherwise,,contaminate surface or groundwater. Date of Issue: i"r 19 Date of Expiration 19— Permit Issuing Official °ermit is Non - Transferrable White copy: HD File Pink copy: Owner 1.89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING,.CARMEL, N. Y. 10512 DESIGN'DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM Oimer c� D�- iJl l ,�i, A c~' FILE NO. �cz 44 * ��� Address Located at (Street I- 114. _'UL _Block _Lot indicate nearesf —cross s ee Municipality, � Watershed 6ZO-TO k SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Ran Elapse "Depth to Water water ve No.. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches l" 1 1z 2 Z aU 2-1 ZZ,. 3 P> (3 - (542, 30 Zl 22-, � 36 4 1 4q, Z Z o, 3 l Z 8 4Z 36 Zl Z Z Y2_ (' �2 26 4 5 1 2 4 5 Notes: 1) Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOIL ENCOUNTERED IN TEST HOLES DEPTH HOLE N0. HOLE NO -: HOLE, NO. G.L. 6" 12" 18" 24" 30" .3611 42" 48" 5411 60" 66" 7211 781 84" INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCO - _ Ng�g DESIGN Soil Rate Used Min/1 "Drop: S.D. Usable Area Provided -- . .� No. of Bedrooms Septic Tank Capacity iZ9) Gals. s - Absorption Area Pro vi ded By F. x24" � '— trend Address aK ZL SEAL a v .... ._. .. . --- THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by Date PC -1 PUTNAM C OUNTY D E PARTMEN T O F H EAL TH z......,A,OPLIEATION.••FOR- APPROVAL OF PLANS FOR A -WASTEWATER :DI sPOSAL SYSTEM- - • <.._. -_y ... �tt 1. Name and Address of Applicant: Z *43 2. Name of Project: 3. Locatio6V /C: 4. Project Engineer: 5. Address: "60K Z43 License Number: 404�0 8 Phone:4 6. Type of Project: E,_,'�Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEAR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is .a Draft Environmental Impact Statement (DEIS) required? ............. I� 0 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 3. Name of Lead Agency 1.. Is this project in an area under the control of local planning., zoning, -or other off ci-alsi- ordinances" .......:....:..... _.._..._ ,,..._ ?. If so, have plans been submitted to such authorities? .................. - r i. Has preliminary approval been granted by such authorities? Date Granted: G. Type of Sewage Disposal System Discharge.'��)!? 'SZ-&Surface Water Ground Waters If surface water discharge, what is the stream class designation ?........ . Waters index number (surface) .......................................... . Is project located near a public water supply system? .................. If yes, name of water supply Distance to water supply . Is project site near a public sewage collection or disposal system ?..... Name of sewage system Distance to sewage system Date observed: 23. Name of Health Inspector: . Project design flow (gallons per day) ......................&. ........ 2. 25. Is State Pollutant Discharge_ Elimination System ( SPDES) Permit required ?.. N) O 26. Has SPDES Application been submitted to local DEC Office? ............... T 27. Is any portion of this project located within a designated Town or State �1 wetland? .................................. ............................... _ 28. Wetland ID Number 29. Is Wetland Permit required? .............................................. Has application been made to Town or Local DEC Office? .................. 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 or NO _ 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 DESCRIBE: k C) 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? Ar_e . a.ny sewage d_ i_sposal _areas . i n. excess of._ 5% _slope,_-. ? . . , ......_ .......... , ",. �` 36. Tax Map ID Number ......:� ?.:��.�. ... ............................... _ 37. Approved Plans are to be returned to: Applicant ngineer 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 pursuan to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: 13ek MAILING ADDRESS: ir' rir «r h� n� «.• r « « r « «« ur « rr « « tv r « « ot/, ark « y rrryir 5r irr r rrr3 « « ur sir I,rr ii «ir ii � rr � r nr � '•s +. o x•c� :5. rrC 113�� C -{ rno Z Q C's C-, i CZn- � Is" -u'i ��03 y^ r Y ' TANK j 2 J 7 S 9 10 1 jj ' 1041 77' 117' 122' 127 1Q�5 s 4. Y 72- C _ f •iv ., ro v , it AT GUfi-9TA IN nRA Al 0 N01[ i-1QU51�. INf::,oRr FROii ' T. Got- DATE-T) i'iY A�..�F- "��`'i�..h`Q �.,Sk.. ... �}.+k _. .. -. :ty u- ,�'":..s� .-.'�. �4.`n �� -�.'w ss :.v �_�vx. T.,. 4xei � -'•f . .... _.. 0 N01[ i-1QU51�. INf::,oRr FROii ' T. Got- DATE-T)