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HomeMy WebLinkAbout1449DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -37 BOX 13 01449 xi r' or r 06 i r- 'r A. I ■ 01449 .` ENGINEER, t Town or map Block separate system d By bate permit' I Isuad Has Erosion ..Con'trof-'4 ri�04mpiited?:_' Has gakbage grinder been installed? I certify that the system (s) as listed ss�in4 -the al�o sis�,w'eks colistivcted essentially as a dopieb of which are'attached),, �and'in dance ��ith 6, q9 8, in accordance with the filido he� .M t ji pate -Certified by.- Any pe conditions resulting from such uss4e. -:A pr6val 'of the so- ­ t 6i n6ll,ind%void available and �the ippiov'jlL'o'j`th' �pr'lvaie­ 'water i6pp ly '41hal I'becbrne "nit Wand vq ioi�hen betorn S -CP�L, W@r 'subj'aCt Modifi lion' or ch ange when,. ln':ih; -judilmani of the, Cciiniv Will ­­ of ca or Hsa.1th,' such :revocation, modification or change, s necessary. Date T it . �,Rnr..o/85-_________. ° } WELL YIELD TEST 1, If detailed pumping WY ELL LOG are available, please attach. MIVH00: O PUMPED t test:; were done is in- DEPTH FROM Water Well ® COMPRESSED AIR ; forration attached? SURFACE Bear- Oia' FORMATION DESCRIPTION tt. tl eter O.BAILED WELL COMPLETION REPORT Office Use Only DEPARTMENT OF HEALTH in 9 D Of Environmental Health ..Services-. • - - --° -- • == -� DURATION PUZ'NAM COUNTY DEPARTMENT OF HEALTH YIELD land Surface STREET ADORESS: WNIVlL UICHY TAX GRIO NUMBER: Idt WELL LOCATION -r (2Z It, NAME: ADDRESS: PRIVATE WELL OWNER ❑ PUBLIC USE OF WELL RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 1 - primary ❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify) 2 - secondary ❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGH•f gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE406 gal. REASON FOR NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION DRILLING ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH �ft. STATIC WATER LEVEL ft. DATE MEASURED J DRILLING ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG . EQUIPMENT ❑ WELL 50INT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENG•fH __ ft. MATERIALS: STEEL ❑ PLASTIC ❑ OTHER CASING LENGTH .BELOW GRADE �- ft- JOINTS: ❑ WELDED THREADED ❑ OTHER DETAILS DIAMETER in. SEAL: ❑ CEMENT GROUT 9BENTONITE ❑OTHER WEIGHT PER FOOT ____.19 _ 1b./ft. I DRIVE SHOE ffYES ❑ NO LINER:OYES IffN0 DIAMETER (in) 'SLOT SIZE LENGTH (11) DEPTH TO SCREEN (ft) DEVELOPED? SCREEN _ _ -DETAILS -..-; FIRST O YES ❑ NO SECOND HOURS GRAVEL PACK ❑ YES GRAVEL DIAMETER TOP BOTTOM O NO SI ;;E . OF PACK in- DEPTH K DEPTH It. It more detailed formation descriptions or sieve analyses WELL YIELD TEST 1, If detailed pumping WY ELL LOG are available, please attach. MIVH00: O PUMPED t test:; were done is in- DEPTH FROM Water Well ® COMPRESSED AIR ; forration attached? SURFACE Bear- Oia' FORMATION DESCRIPTION tt. tl eter O.BAILED WATER E) CLEAR TEMP. _ QUALITY O CLOUDY HARDNESS- 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES ONO STORAGE TANK: TYPE PUMP INFORMATION CAPACITY GAL._ TYPE CAPACITY Atb l LM NAOATT & SONS, INC. MAKER DEPTH ADDRESS Well Drilling slGrirfTtlRE MODEL VOLTAGE HP Rte. 311 R.R. 2 Box 171A PaTT. ' SON, NEW YORE( 12563 DATES1/ ace. 11 OTHER ; ❑YES ❑ NO in 9 D WELL DEPTH DURATION DRAWOOIVN YIELD land Surface ® Qr� It, hr- min. ft, gpm• oo 6 WATER E) CLEAR TEMP. _ QUALITY O CLOUDY HARDNESS- 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES ONO STORAGE TANK: TYPE PUMP INFORMATION CAPACITY GAL._ TYPE CAPACITY Atb l LM NAOATT & SONS, INC. MAKER DEPTH ADDRESS Well Drilling slGrirfTtlRE MODEL VOLTAGE HP Rte. 311 R.R. 2 Box 171A PaTT. ' SON, NEW YORE( 12563 DATES1/ ace. PUTNAM COU1UY DEPARTMENT OF HEALTH DIVISION OF ENVIRONiMUAL HEALTH SERVICES 61MI�91-- Aamc Owner or Purchaser of/Building Building Constructed by Location �- �Sttreet ( //�% /O'Zare Municipality Building Type G / /Xa �n Block &t %W- Subdivision Name Subdivision Lot #. GUARAN= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM /& represent thatk Wwholly 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 jOig- 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 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 bui in til, the system. �•'� Dated this _ day o 19 Signature Title 1 f General Contractor (Owner) - Signature Corporation Name (if Corp.) Address ° rev. 9/85 mk 1 ` cam, i Yorktown Medical AB N ratory Inc. — 321 Kear 5treet • .. s .- .. .. _ Y_ o rkto. _w..n . -H Date-Taken: -7 !1 g Time 7 j ayrl e s. N...Y- i0598 _ D.a.t ev R c ':d :.._ T i m e 7700 m' (914) 245 -3203 Date Reported: OUL. 1 1386 Director: AIbcrt H. Padovani M. T. (ASCP) Collected By: BIAGGIO RIINA Referred By: r 1 Sample Location: KITCHEN TAP: COLONIAL RIDGE ASSOCIATION DJ P�evr� "v t 495 MAIN STREET Phone #273 -8228 ARMONK, NY 10504 Phone X I Sample Type: J L Repeat Test? _ (check one) LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC NON - METALS (mg /L) MICROBIOLOGICAL (CFU. /100mL) Acidity _.Alkalinity Chloride Detergents, MBAS Hardness, Total Nitrogen, AmmonilL Nitrogen, Nitrate Phosphate, Total Sulfate _ Sulfide Sulfite METALS (mg /L) Copper _ Iron _ Lead Manganese Mercury Sodium Zinc MISCELLANEOUS pH (units) Color (units) Odor (TON) Turbidity (NTU) GENERAL BACTERIA Standard Plate Count 5 (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform 0 Fecal Coliform :ecal Streptococcus MOST PROBABLE iiUMBER TECHNIQUE Total Coliform Index Fecal Coliform Index KEY FOR TERMINOLOGY CFU = Colony Forming Units N/A = Not Applicable LT = Less Than ( <) GT = Greater Than (>) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non- reactive i/Potable _ iion- potable _ STP I NF _ STP EFF Other: Sample Status: (check each) Outgoing HNO3 _ HC1 H2SO4 _ NaOH ZnOAc Na2S203 Other. Incoming I Lr 4 °C 40C pH LE 2 _ pH GE 9 _ DH GE 12 Other. REMARKS /COMMENTS (For Lab Use) IELAP X10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THV,,N YORK..STATE DRINKING WATER STANDARDS, FOR THE.1'ARAMETERS TESTED, AT THE TIME OF COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) N /A) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT DR NKING WATER CODES, FOR THEAP.tAKfETERS TESTED, AT THE TIME OF COLLECTION . Ix/ 1 Albert H. adovani, M.T. (ASCP), Director 2 /86(Rvsd7 /87)RWE •Building -Lot Area L.4 0q. Onii, =:P,pp-th inns Fill' Design F16w 134/D completed N*inbe.r of Bedrooms- PCHD Notffleid6n Is Required When JFM Is �6 e tons to consist of on 'septic Tank pu ;S�P—",Sew isgo Sys anA om o lie constructed bl., A.d&vw water SuPPIJ Pdbllc Sapply From Address iy 1jrMod by - t 0j. Privill �S.� ii Other ]Requirements, and -am whot y iln -he I re resent i I an completely rpsponsible for the,jes!S iociiion 'of't proposed system(s) I that the separate- sewage. disposal system ab6ve described will be'constiucted asIhown on the ipprovid amendment there to and in-iccordancb with the standards, rUlej and regulations-of ther �Purnam i:94nt 1. y.: . Department 1. t, of .. Heakh,-�.and that 6_h,6mpioiion thereof a ,'Cort if icate'. of ..,Construction'ComPninc r e-I I I , satisfactory't 1 0 . the cdmmiisioner` of Aealt , hwill :66,submitted'to the- Depirii;nenii "'and' a 'written guarantee: wilt be furnished ' the owner, his successors, heirs or :assigns,by the'buiicler,'that sald,b6ilder'-will p- in"966d .operatin*q condition , . t oi',:said. sewage. disposal iysiom,'durin the period of two (;) -years Immidiatel . y foll . o Wing theAat I e.-of,:ihe­issu- any,. par r 9 , , , , . . . - , . � 11, . , , . once 'f:thii 'a 'r 'i of iho'Cortific"ate. of C onitiuCjinn, Compliance of' the original system or any repairs thereto; 2) th i drilled well described above • 0 PP Ova will,be located as� sh n the d lari and that said Y;Gll.:will be. installed i ith the. .s dards, ►ul nd rag aUans, of.,,;th Putnam o�w aRp�ove 'P. IT 7 f -County, D h imp 9,� Date - �5' ned P E R _v No Addresk— Li nse 1ppro�ai expirell one ' bar fr n APPROVED FOR CONSTRYCTIPN:. Th,is'� ne ye4r-fr revocable for fer)d.d or modified '"on considered Ao I cause r I : requires a P.P". A rr 4 for disposal of domestic sanitary Date By MITA FALMAWAWWWAIIIIIIII 6ui ding has been-.undertaken and is change orAalteratioin of con>jj 6666n ' APPENDIX B -nr7 -mM rrwnz Y DEPAREMEM OF HEALTH - DIVISION OF HEALTH SERVICES IDIDIV�UAL VU= SUPPLY & SUBSURFACE SEW AG DISPOSAL SYSTEMS J2EV3FW SHEET - IONS 1M- UUIION- ..PERMIT__.. J,_ , DATA BY: (Name of Owner) (Str t Location) 1'I,S NO DOCUfl= Permit Application Corporate Resolution Plans - Three sets Engineers Authorization 1 Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth L� �vor�ri'1 TYP'tt71 (�� A -- required �7�_ .0 .arellel to -7EME mom 0� MGM s/s SUBDIVISION Perc_ (3) Fill cd House Plps - Two sets Well // permit; PWS letter er Variance Request GENERAL ' Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Tcwn/DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Di,- nensions - Volume D or J Box;Trench /Gallery; Pump 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 E xpa sion Area; shown; gravity flow, suff. size If Pimped Pit & D Box Shawn & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type Pipe No Bends; Max. Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top 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' tram Foundation; 50' to well 15' Well to PL i DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #1�. WELL LOCATION Street Address Town/Village/City Tax AJ, Grid Numbe Z� WELL OWNER game M fling Addres V �. Wrivate O Public USE OF WELL 1 - primary 2- secondary QBBSIDENTIAL O PUBLIC SUPPLY O BUSINESS O FARM 0 INDUSTRIAL 0 INSTITUTIONAL Q AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY 0 ABANDONED O OTHER (specify 13 AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE QZ�0 Ogal REASON FOR' DRILLING SUPPLY ffREPLACE[EXISTIIJG OPROVIDE ADDITIONAL SUPPLY SUPPLY 0 DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE Mi tRILLED 0 DRIVEN EIDUG. O GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES C/ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name —17 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES (,,"NO NAME OF PUBLIC WATER SUPPLY: DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: TOWN /VIL /CITY LOCATION SKETCH.& SOURCES OF CONTAMINATION PROVIDED / r_ []ON REAR OF THIS APPLICATION [gl SE ET 1� g date) (si nature) 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 W 11 Completion Report on a form p vi d the Putn m Cou Health Dep rtment. - Date of Issue: U. 19�_ Date of Expiration: 19 a mit IsskAW41 Official white copy: H.D. File Permit is Non - Transferrable Yellow copy: Building Inspector Pink Copy: O.-mer 287 Orange copy: Well Driller Division of r-nvironmental Sanitation AFTIDAVIT COR.POR;M: (UNER APPLICATION TOP PER"117 JA-PPIATC."ITION SUB)MOTTED TO CQUKTY 0 - TO: C c, r7,.7 .; s s �-' o n e r o appication for — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — ---- — — - —— - - - - - - - - - -- - - - - - - - .-Flat 1 a7 a r i o If e C I- e 0'-r thE C am7',- x`3071 a nd - B m t�) or S z e d C)r DID- Or E �ces a- h, a Lam..... — — — — — — — — — — — — nc-se — .1 I o j "cers arc- I:!.: A Ll -S 71 71�no 'c t s C2 P L, t L Fri 8 e fO 7' En N, or all t h 5� e 2. a n J a 11 S u b, L I-— S7 t a o 5 re a ni- t 4) be4,0Ze L -his A JQ y e 7-1 e4 j c LINDA R. BURPEE Notan, Publio, State Of NOW York No. 4808377 oualil ied in estcheStef COurdy Commissio VVn Expires rsol-"w CI)36/58, .­� I C0 r. "7^, -ate . �e a I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL.HEALTH SERVICES COUNTY -OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner nb�ie�L � ia- t�7 ac- Address 4- lA©e v8� ?L. A VU37 A•vvAo A_) (< iJ Located at (Street ����i,,u� Block 1 Lot -1-1 �1n ica e nearest cross street) Municipality ,y Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIMEF 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 1 O 2 96 P 3 D 37 .� 0 1� 19314 -1 3 1& 111 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 SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO ( HOLE N0. HOLE. NO. G. L. vat �°4 7 6" 12" =WI` _ 1811 1 � 2`t" .(1 30" , r 36" 4211 h 4 it i 5411 of 6o �t 66" � 72,11 7 811 84„ J v Q G X98 "i �, INDICATE LEVEL AT V1HICH GROUND WATER IS ENCOUNTERED - INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUN TESTS -MADE" BY ... LLV i V 1. Soil Rate_ Used f�r30Min/l "Drop: S.D. Usable Area Provided No. of Bedrooms 4- Septic Tank Capacity `Z Gals. Type 0 Absorption Area ]'rov1_de By�L.F.x24" 36" width trench. 191i1A1 %, f- •-• THIS SPACE FOR U3E BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Cal. Checked by Date y a. z i �Ilz z � � a) ,i 1, .f t � v . P � rt S i, b .' 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