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HomeMy WebLinkAbout1436DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -22 BOX 13 01436 0 1, .: 01436 �F7771 1­7 PUTNAM COUNTY DEPARTMENT OV HEALTH ' R 186 Division of zvr ozneniiHeWth'Serife 105h. 'Engineer Must, Provide - ­­ : V C D; Permit CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM % Town or Vula' 0 -TO �g Tax Map, I't ?--Z- -Block— L at F . e' C or t Name 41w COP!5T, PFA) Forme Subdivision Name Subdv. ut # ot, p can M-11 . Ing Address 10 CO-1-n ZIP 12563 Date Permit issued Separate Sewerage, System. built by L1BRA Co Address J> 0- B& 514 Consistlig of 400 Gallon Se P t,. Tauk and L.F. Water Supply: —Public Supply Brom Address Private Supply Drilled §y� Address Building Type 1116s. Erosion Q.)n'trol Been Completed.? `fie S Number of Bedrooms Has Garbage. Grinder Been Installed? Qo Other Recialr6ments I certify that the a atem(d) as listed as ing the above premises tiara structed essefi illy as M the•plans of the completed work copies . _y TV Oman, of which are attached), and in accordance with the standards, rules and "r qulations ccprdanc .4 J i . the filed plan, and the permit issued by the Putnam County q pament Of Health:. Date Certified b P.E.- R.A. Addr ass 2CZ I rXt, e%"Ak tltsit - License No. Any person occupying promises served,by the above system($), shall promptly take such action as may be necessary to secure the correction of any unsanitary esulting from such Usage. Approval of the separate sewerage system shall become null and void as soon as a pub,% unitary Bawer becomes available n old a ble. :nd the- approval' of iihe'piriva,e water supply "hill'tiaccirivi ' null' d v Wh n a public water supply, Ovalle Such approvals are sW". - "B subject to,olodification or change. "in, in the judgment of the Commissioner Of Ha ilia s. ch revocation, modification or change Is net" ry. Date Title Ir j: .1 PuTNAM CoUlIfY DEPARTMaTr OF HEALTH DIVISIOiq OF ENVIRONMENTAL HEALTH SERVICES fj Owncr or I'Lirchascr of rluildiiiq Suilding.Constructed by tocaj6p ri Stt6k AT Municij)Kity Building .Type' -3 � --,,7 '2- a- Secti.9n BI.c.x-k Lot 14,11, .4.0 e_ 6Z Subdivision Name r pv, tw zi 14- Subdivision Lot GUARAN= 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 t ' he 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. TI 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 t 19 Signature Ti: -04 7�-, eraf Contra r_�t (Owner) Signature 5 e Corporation Name (if Corp.) _Tkael 0.94� Corporation Name (if Corp.) Address Address rev. 9/8 - 5 mk NORTH AMERICAN. LABQRATQRIES, INC. ....M, . LABORATORY REPORT TYPE: P W LAB ID NUMBER: 95 -0252 CLIENT: Libra Construction PO Box 516 Patterson NY 12563 SAMPLING LOCATION: Kitchen .ap; Lot #8, Highview Dr, Patterson NY DATE COLLECTED: 01/19/95 11:30 AM COLLECTED BY: J. Costigan DATE OF REPORT: 01/23/95 ANALYSIS - RESULT UNITS . � METHOD ANALYZED Total Coliform E. Coh Absent Absent Colilert 01/19/95 This sample, as collected and submitted to the laboratory, did meet the requirements of the New York State Sanitary Code Part 5 -1 for bacteriological (sanitary) quality. Laboratory Director NYSDOH ELAP #11218 618 Clock Tower Commons, Rte 22, Brewster, NY 10509 / 914.278 -7600 / Fax 914- 297 -0536 Jam' WELL COMPLETION KI!:YUKr Office Use Only DEPARTMENT OF HEALTH Division Of Fftvironmentai- Heal°i:fi•=�e�vlces OF HEALTH PUTNAM COUNTY DEPARTMENT I STREET AOURESS: WN!vl /. - ^' fJ��NUMBER: WELL LOCATION , Highview Drive. Carmel NY j Lot NAME: ADDRESS: "" O PRIVATE WELL OWNER Libra Construction, PO Box 516, Patterson, NY 12563 O PUBLIC USE OF WELL Ja RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED 1 - primary O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify) 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR ❑REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY DRILLING ©NEW SUPPLY (NEW DWELLING) ❑ pEEPEN_EXISTING WELL DEPTH DATA WELL DEPTH 1 15 ft. SIAIIC WA I-ER LEVEL _It. DATE MEASURED 11 1 DRILLING l3 ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING jUOPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH __ —mil ft. MATERIALS: , ID STEEL O PLASTIC O OTHER LENGTH BELOW GRAD E ft. _6 JOINTS: O WELDED 99 THREADED O OTHER CASING DETAILS DIAMETER in.- SEAL: 0CEMENT GROUT O BENTONITE OOTHER _ _ _ WEIGHT PER FOOT i —_19 _ 1b./It. I DRIVE SHOE ® YES ONO I LINER: CJYES UNO DIAMETER (in) 'SLOT SIZE LENGTH (11) DEPTH TO SCREEN (ft) DEVELOPED? SCREEN - DETAILS FIRST OYES ONO SECOND HOURS GRAVEL PACK O YES GRAVEL DIAMETER TOP BOTTOM ❑ NO SIZE: OF PACK in. DEPTH ft. OEM IL WELL YIELD TEST It detailed pumping I�IEI.L LOG It more detailed formation descriptions or sieve analyses are available, please attach. METHOD: ❑ PUMPED tests were done is in- DEPTH FROM Water w °11 � XXCOMPRESSED AIR , !ormation attached? SURFACE. Pear. D13' FORMATION DESCRIPTION cou O BAILED O OTHER :DYES ONO 1t It ;oa near WELL DEPTH DURATION ORAWOOWN YIELD Surface 6 Dr .1l..ng in overburden clay & boul er ft. hr. min. It. 9pm. Hi r ck at 6" 24 6 180 6 r ng in roc , se casing, grou J e 31 _G.5 Dr 11 ng in rockc granite. WATER O CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO By Owner ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GATT. PUMP INFORMATION - TYPE submersible CAPACITY 7 g WELLORILLERNAME P.F. Beal ons Inc. OAT 6 MAKER Gould DEPTH 2001 AoDRESS 4 Putnam Ave . SIGNAN MaoEL7EHO541z VOLTAGE230HP _ Brewster, NY 10509 u 10 Lfe�bi fit Toi, wMic on w Tmi404 MWWA ------ PF ------- —41F gal ,!tftr* O1 Hftoh will '. "W Silid btlikiw vkIl rs—ot this .Putftaj" DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 Al PI;1CAi'ION' TO CONSTRUCT"A WATER YELL' PCHD PERMIT I WELL LOCATION Street Address i ✓' �'vc own Village City Tax Grid Number .tJ 3 4 — WELL OWNER ame '� M fling ddres DaffeW _54 f,f e.) Private t. 4 1" .0 S! O Public USE OF WELL 1 - primary 2 - secondary )K RESIDENTIAL ® BUSINESS ® INDUSTRIAL D PUBLIC LY Q AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /41 PEOPLE SERVED_ /EST. OF DAILY USAGE Ldvowgal REASON FOR DRILLING ® REPLACE EXISTING SUPPLY 19NEW SUPPLY NEW DWELLING ® TEST /OBSERVATION L3. ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING `w 1. - Aj c use WELL TYPE DRILLED ODRIVEN ODUG ®GRAVEL. OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUB IVISION, N OF SUBDIVISION: .m `' �e2< .,, -b� v, ss�+ En Lot No. jE�p WATER WELL CONTRACTOR: Name Aeo ; 50f5 Address : vto ` 3eeAeste , A) V, IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: - TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:�---- LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ifSEPARATE SHEET , 3 (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 thirt�c (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 conta ' ate surface or groundwater. Date of Issue: 19� Date of Expir on 19� Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PC -1 b` P UT NAM COUNTY DEPARTMENT OF HEALTH - - - _ rCVt -- rPROVAL- - -- F='PL'ANS.:FOR 'A -- tV rVA7 EF= -Q:ISP TEV� 1. Name and Address of Applicant: e14' "Pal 3soti 2. Name of Project: 4�8 3. Location T /V /C: 5. Address: 4. Project Engineer: pp License Number: wm� Phone: 265' )o3z" 6. Type of Pro ect: private /Resident Apartments Office Building 7. Is this project subject Type Status (Check One) ial Food Service Commercial Institutional Mobile Home Park Realty Subdivision Other (specify) to State Environmental Quality Review (SEAR)? Type I.. Exempt Type II. Unlisted ✓ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 1J o 9. Has DEIS been completed and found acceptable by Lead Agency? ........... N1�' 0-) 10. Name of Lead Agency _ t1._.Is this..proect in an area- under the control, of local planning, zoning, �5. or other officials, ordinances? ........ ............................... *e 12. If so, have plans been submitted to such authorities? .................. 13. Has preliminary approval been granted by such authorities? `t5 Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water ✓ Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 1tv 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? ......:............ 00 water supply N�� Distance to water supply A 18. If yes, name of 010 19. Is project site near a public sewage collection or disposal system ?..... 20. Name of sewage system pI� Distance to sewage system uF� 21. Date observed- gez "bte., 23. Name of Health Inspector: � 6 L) 24. Project design flow (gallons per day) ......... ......................... 2. ._•_ . •. . _._ _ •- - •_-•-- ~ ° ";ischar�e 'El-iminati•on• System (SPUES)`-Pe�rm'tt'`raqui red? � •=;-` •-��a "" � "� ° " "'� 25. Is State ~Pollutant Discharge 26. Has SPDES Application been submitted to local DEC Office? ............... 1,a 27. Is any portion of this project located within a designated Town or State wetland?* etland ? ..................... ........... ............................... o 28. Wetland ID Number .............. ............................... 29. Is Wetland. Permit required? .............. ............................... Uo Has application been made to Town or Local DEC Office? .................. �) o 30. Does project require a DEC Stream Disturbance Permit? ................... 13 c 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, �o 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 No any other potential known source of contamination? ..............YES or NO DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ........... `ic5 34. Are community water, sewer facilities planned to be developed within 15 years? 35. Are any sevage disposal areas in excess of 15% slope? 3y_Z -ZZ 36. Tax Map 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. 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 Sectio4 210.45 of the Penal Law. �- SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: �y as Le; SEPARATION DISTANCES IN FEET / 2 3 4, S 6 7 8 8 10 // 12 13 14 13 16 19 Nr z8 3L$ 36 4►. 4G SI SC-9 SO,S 77.5 76 7S 65 63.5 71 a s 25•S 30 32 3f.131 p3 47 S3 81.5 79S 78 7 CSS 47 7G e � ' 7 � 4 6 9 5 y loe 4 a I2 13 2' 13 cpf 14 a .1 15 4P� � 1 u O R 2 r to a f` dp N�4'S3�52 "W--�' ?8.00 !ey Z25.po• S I A • J•