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HomeMy WebLinkAbout1456DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -44 BOX 13 : z. -V"- kc T; i g` 01456 Rev. 3/86 YUTNAM COUNTY DEPARTMENT OF HEALTH - . '" Division of Environmental Health Services; Carmel, N.Y..10512 i Engineer Mast Provide P.C.H.D. Permit q " : _ CERTIFICATE. OF. CONSTR CTION. COMPUANCE FOR SEWAGE DISPOSAL SY8TEK_ �.- --- - � Town or Village Located at V 'L �t l.�t o•,.- L 44,ems, Tax Map ---,L� Block a-- Lot Owner /applicant Name T, 1l • L �a. i • C Formerly Subdivision Name 94 Subdv. Lot q 2-6 Mailing Address 0 93 y x, zip ? �� Date Permit Issued l n 2'7 - 22 Separate Sewerage System built by >> L/ - y t Le-, &%g / l Address Consisting of G6 0 U Gallon Septic Tank and Water Supply: Public Supply From Address ( or: �° Private Supply Drilled by • � • �� s�"t f Address �r Cl 1 ! PS2 �.�o = � . Buflding Type t 4, JLss , Has Erosion Control Been Completed? VI-11 Number of Bedrooms Has Garbage Grinder Been Installed? ! r 6 Other Requirements 'I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the p ana of the completed work ( copies of which are attached), and in accordance with the standprds, rules and regu a ions, in accordance with the fil pl the permit issued by the Putnam County 7Department Of Health. DateT —� 17 f tif(etl Y P.E. R.A. Address' / License No._�L Any person occupying premises served by the above systems) 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 sewerage system shall become hull and void as soon as a publ;: sanitary sewer becom- available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals s subject to ification or change when, in the judgment of the Commissioner of Health, such revocation, modification or change Is necessary. �/ r Title Date 8Y : ,�. CO .1'.sf• V °� TTr.+T T �/1XAnT L1TTnK1 a _ YYLLL I!,Va DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNki COUNTY DEPARTMENT OF HEALTHk6-t4a- � Office Use Only _ I WELL LOCATION STREET ADDRESS: TOWN171CLACEM IIY Tax GRID NUMBER: WELL OWNER NAME' ADDRESS: �- PBIVATE PUBLIC USE OF WELL 1 - primary 2 - secondary YRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED O BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. 1N0. PEOPLE SERVED / EST. OF DAILY USAGE �0d gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY F2(NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL . DEPTH DATA ` WELL DEPTH ft. STATIC WATER LEVEL �3 _tt. DATE MEASURED 7 DRILLING EQUIPMENT C3 ROTARY COMPRESSED AIR PERCUSSION C] DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH ft- MATERIALS: STEEL ❑ PLASTIC O OTHER LENGTH BELOW GRADE �_ ft. JOINTS: ❑ WELDED THREADED ❑ OTHER DIAMETER in. SEAL: ❑ CEMENT GROUT O BENTONITE OTHE WEIGHT PER FOOT /S Ib. /ft. DRIVE SHOE. MES ❑ NO I LINER: 0 YES NO SORE DETAIL DIAMETER (in) 'SLOT SIZE L GTH (1t) DEPTH T SCR -N (1t) DEVELOPED? FIRS( ❑ s ❑ NO S NO POF HOU GRAVEL PAC o NOS GRAVEL SIZE: METER ACK in. TOP DEPTH --ft. BOTT ht DEPTH It. WELL YIELD TEST If detailed pumping M tHOD: O PUMPED tests were done" one is in- COMPRESSED AIR , formation attached? O BAILED ❑ OTHER O YES O NO WELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing Well Dia In FORMATION DESCRIPTION woE ft !t WELL DEPTH It. DURATION hr. min. DRAY' 10OWN !t, YIELD ggm. Land ce uria 0 'so Q 11 90 2Z_ 6 3 WATER CLEAR TEMP. QUALITY 0. CLOUDY HARDNESS O COLORED ANALYZED? D YES ONO ANALYSIS ATTACHED? ❑ YES O NO STORAGE TANK: TYPEW, /l CAPACITY GAL. w 11 DRILLER NAME DATE M, {��i� f is S�. ; l C• �� SiGTr3fTt)RE k;.c WOII Dr�hlirjg !' ? A PUMP IH ORMATI N (�/�1 �,,AT CAPACITY Y___ � DEPTH r6 MODEL S� % ^ / _may_ VOLTAGE HP 1 V/ _J a PUTNAM COUNTY DEPARTKRU OF HEALTH ' _ ..DTViSION OF ENVIRO a 'T $EALTHI SERVICES Cc, Z Owner or Purchaser of Building Section Block Lot Building Co�n%s'tructed by I,ocac�tiion - Street X Subdivision Name / Q `GYfaLl / `F Municipality Subdivision Lot v Building Type G{]ARA = 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 sham 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 deteimination of _ the Director of the Division of Environirental 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 utilizin the system. Dates this day of 19-2a Signat e Title �GEeral /tor (r) - tore Corporation Name (if Corp.) Corporation Name (if Corp /) ess rev. 9/85 mk TYPE: LOCATION: REPORT TO: ADDRESS: CITY, STATE, ZI DATE COLLECTED: TIME COLLECTED: ANALYSIS DATA SHEET wN Lot 20, Jenifer Lane JV Construction, Inc. Box 449 P:Patterson, NY 12563 08 -03 -93 7:30 COLLECTED BY: Jerry REPORT DATE: 08 -05 -93 i SAMPLE: 93 -3576 SAMPLE SOURCE: Patterson, Winsor Oak DATE ANALYSIS RESULT UNITS METHOD ANALYZED Total Coliform MF Absent SM 17 (9215D)08 -03 -93 THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET THE REQUIREMENTS OF NEW YORK STATE DRINKING WATER STANDARDS. 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 V) M C) C) U- CD ClIL L;j 0 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 TO . CONSTRUCT . A ., WATER _.WELL _-. -> : _ :.• -- :_��//����'��'' PCHD PERMIT WELL LOCATION Street Address Town Village City Tax Grid Number LA'N 2� WELL OWNER Name Mailing Address v L//vo-TIU1010M 60. ®Private O Public USE OF WELL © - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 9 BUSINESS O FARM O TEST /OBSERVATION O INDUSTRIAL C] INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED � /EST. OF DAILY USAGE ©D gal 'REASON FOR DRILLING ❑ REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY t9 NEW SUPPLY NEW DWELLING) 0 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING ! 12 WELL TYPE CODRILLED ODRIVEN DDUG C]GRAVEL 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES f, NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_ Lot WATER WELL CONTRACTOR: Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES V NO NAME OF PUBLIC WATER SUPPLY: N/A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:,_ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE n o, taON SEPARATE SHEET (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 thirt3, (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 ma ner as not to degrade or othe wise contaminate surface or groundwater. Date of Issue: 2 19� 2!_! Date of Expiration Permit is Non - Transferrable 3/89 19� Permit Issuing OfTlicial White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller APPENDIX 3 ,UTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYS REVTE EET for - - -- „rTS9lT'Tl1 OF L __. DATE DOCUMENTS. z 'ERMIT APPLICATION C 'C -1 VELL PE WS LETTER NGINEERS AUTHORLZA )ESIGN DATA SHEETME )EEP HOLE LOG :ONSISTENT PERC RESL 'ERC HOLE DEPTH_ ;ORPORATE RESOLUlIC 'LANS THREE SETS [OUSE PLANS - TWO SE: VARIANCE REQUEST GENERAL EGAL SUBDIVISION UBDIVISION APPROVAL CHECKED ,�'_- --� ERC RATE III REQUIRED :URTAIN DRAIN REQUIRED IDES -- :X- APPROVAL SSDS ADJ. LOTS JETLAND (TOWN/DEC PERMIT R & D) ►ATA ON DDS PLANS & PERMIT SAME RE- 1969 -NEIGHBOR NOTUMCATION ETTER BI/ZBA �--- — m TAX MAP # & DEEP HOLES LOCAT D SENTATIVE OF PRIMARY AND EXPANSION RZAREA; SHOWN; GRAVITY FLOW, SUFF -SIZE ED PIT & D BOX SHOWN & D� @I1S NO.OF BIDROOMS S & SSDS'S W/IN 200 FT. OF PROPOSED SYSTEM �.�, p�pF;RTy METES & BOUNDS Ltd HO ETBACK NECESSARY (TIGHT LOT) OU EWER - 1/4 "/FT. 4"0; TYPE PIPE O BENDS; MAX. BENDS 45 W /CLEANOUT FILL SYSTEMS so ■■ 2 ro : SLOPE 3:1 TO GRADE DFrPTH GAUGES FILL PROFILE & DI'1riENSIONS TRENCH PROVIDED TO CONTOURS 100% EXPANSION PROVIDED _ _ -. 00 YR FLOOD ELEVATION �FIEL,/DS FIRED DETAILS ON PLANS 10' :L., DRIVEWAY, LARGE TREES, TOP OF FILL EWAGE SYSTEM PLAN - (NORTH W) TO FOUNDATION WALLS SDS HYDRAULIC PROFILEA�4I� W O WELL, 200' IN D.L.O.D., 150' PITS V J BOXED TRENCH/GALLE - PIT D AILS SCAM WATERCOURSE LAKE (INC.EXPAN) EPTIC TANK - SIZE, DETAIL ATCH BASIN, 35' STORMDRAIN, PIPED WATER TELL DETAIL, SERVICE LINE IF OVER i' O WATER LINE (PITS -20') ONSTRUCTION NOTES (GRINDER ESIGN DATA: PERC AND DEEP RESULTS -� WO -FOOT CONTOURS EXISTING & PROPO RIVEWAY & SLOPES CUT DOTING /GUTTER/CURTAINT DRAINS RENTS: RMITTENT DRAINAGE COURSE 200 FT. RESERVOIR, ETC-ED 150 FT. GALLEY SYSTEMS SEPTIC TANKS 10' FOUNDATION; 50' TO WELL WELLS 15' WELL TO P. • Putnam -ounty Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT. APPLICATION SUBMITTED TO :. PUTNAM COUNTY }(EALTH DEPARTMENT, i • Tb: Commissioner of Health - In the matter of application for represent that I am an officer or employee of the coorporation and arh aut}ioriied to act for (name of corporation) t having offices at _ �.1 �'e].� �� ZVI. _'__--- ___..___...__ Whose officers are •• President �,� ���— ame and •ddres, Vice- President si '(Name and Address) Secretary— __ ^_ —_ _ (Name and Address) — " _ — 27ea surer - .- _.._.__w_..�._ "(Name. and Address)— — • — and that I am and will be individually responsible for any or all, actp of .the corporation with •respect to the approval requested and all* sub- : Sequent; acts releting_tliereto.' Sworn to before me this day Si ned g o f 19 � 7 Title N t y Public ' JOANNE M: MASC(N Notary Public,'State of New Yor!( • Qualified in Putnam County Q Commission Expires Lac. 29, I9, wit • •� :' � - �'' fit; l � , Corporate Seal PUTNAM COUNTY D E PARTMENT O F H EAL TH APPLICATION FOR APPROVAL 'OF PLANS FOR WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant:" 2. Name of Project: ���b �� 3.._. Location /C: 4. Project Engineer: U- ,V?� �2 . Q(6R0lS� �f�Yz_. 5. Address: License Number: 56 Phone: -107I 6. of Project: T V 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? ............. fie 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 10. Name of Lead Agency tdA, 11. Is this project -in an area under the control of -local planning zoning - - or other offs "cials; ordinances? .. ..................................... Flo 12. If so, have plans been - submitted to such .. author .sties?.:................... 13. Has preliminary approval been granted by such authorities? ` Date Granted: / 14. Type of Sewage Disposal. System Discharge...... I Surface Water ✓ Ground Waters 15. If surface water discharge, what is the stream class designation? ........ l�r T 16. Waters index number (surface) ........... ............................... tJ� 17. Is project located near a public water supply system? .................._ ' 18. If yes, name of water supply _ k; /}k Distance to water supply 19. Is project site near a public sewage collection or disposal system? ..... mod 10. Name of sewage system _.. s�4A Distance to sewage system 11. Date observed: I -22 -�JZ 23. Name of Health Inspector: Lt /,1�1:�G- S :4. Project design flow (gallons per day) ....... ..............................G r 2g_. _:Ls.: State. PolTutentrDischarge� Elimination System - (.SPDES) :.Permit:-requi,r.-ed ? -:: _ .- -- -U- i9_- . 26. Has SPDES Application. been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or State wetland ? ................ ............ .... ............................... 28. Wetland ID Number ........................ ............................... _ 31A 29. "Is Wetland Permit - required?". ..°..°°...... >. °... °... °.. °.o... .......... 0. jJa Has application been made to Town or Local DEC Office? ...I ............... 30. Does project require a DEC Stream Disturbance Permit? ................... 06 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 d. 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 lD DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ........... Yf- 34. Are community water, sewer facilities planned to be developed within 15 years? U N _..35__: Are_. any.._sewage._.dispasal - _areas in.excess - -of 15%. slope?..._..°,. ,.... ... ... ....�._.�......._._. 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 y-a Letter. of Authorization: Failure to comply with this. )rovision 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 Section 210.45 of the Penal Law. "1 /7 ;IGNATURES & OFFICIAL TITLES: 1AILING ADDRESS: TA r1�O� KLi lf"5i6:�7 __ �1. ROWANDOMANK120 w., i .•. 1� Y• -1 �- .1a. DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. VD`��f 2b fie- r \� G / %I��`�U�iT�Di�L GD Address i'/1 OiJ`, T-- Iccated at (Stre-et) ��' 1J1�11 ��� I�� f\1 Sec. '5j�t Block Z I,ot . (indicate nearest cross street) Municipality jam/ :uc- rcll�-0 f j �1. �_ Watershed SOIL PF.RCOLAT CN TEST DATA RDQUIRED TO BE SUBMI= WITH APPLICATICNS Date of Pre- Soaking -2 Date of Percolation Test q 2 2, HOLE NCZmm CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Tim Ground Surface In Inches Soil, Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 1 1a-2r27- 10 :1-7y '�0 2 �'�i3f9> 1110 2 2 11, 3 II. -�7-T _ II 4 5 1 z5', I/, 101- l3 11: Zvi , II �� �o ;'. 2�} � � 1� /a' 1,7 4 3 4 b 5 MM'Tmm 2A 4A I /a, f I 5 NO'D'S: l.' Tests to be repeated at same depth until apprc ximately equal soil rates are' obtained at each percolation test hole. All data to'be suimitt�d for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED • BE SUBMI= W= APPLICATION DESCRIPTION OF SOILS EN(XXknMED IN TEST HOLES DEPTH • o . HOLE ►. i HOLE Nol 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' _LEVEL AT WHICH GROUNDG� IS ENMUNTERED � .INbIC�TE LEVEL TO WHIC" WATER LEVEL RISES AFTER BEING ENOOUNTERED H©L,E OBSERVATIONS MADE BY: DATE:. DESIGN Re Use i1" Drop: S.D. Usable Area Provided Dl- Se tic Tank Capacity No: of - �Sedroans p pa tY 1 d GD a-'s - Z`YPe Go , Absorption Area Provided By L.F. x 24" width trench Other Name Address '[� ?j -AI I✓W- 0:5 (� 2 THIS SPACE FOR USE BY 'HEALTH DEPARTMENT ONLY: Signature: R1" OF NEW Y, z �P No 56124 \pROFESSIONP,,I Soil Rate Approved sq.ft /gal. Checked by Date k Z I F _ Ca�O. L, CTYP ro 49' I W v 3Q� v O Q v 139. Zs tq-- 12�lDEN�i� _ Ca�O. L, CTYP ro 49' I W v 3Q� v O Q v 139. Zs - - f, ,e5l __ I -1- I 11 - I . I -1 , � , , 1 :�� I - ll� ­'�*z­_, _-�."� � � � , , - - ,,r,..._5_ . _t�� .,P,� I ­_ , I I . 1, 1_ v ­-�, "' , � ­,� - " .-,g,­- 1'?; � � , k" � F�� n- - � - , � ,�, . - �e ­,,,�,'­., - �,7. ;�� �;,.� - .1 - ,_�-'­ ­�. - ­ ��j - I . 1, e,,, �_­ � -'e'- %� � , " , � f- , _� - ll�*� -��4-`­,,-,��,att �- '­f: ,��.��I­l A,t_"�F, .1f-11, " - . , - I .,? - , � . , � ..­�al_ � 1. " - � �� . I - , , - , I ,�� -4,�,- - � - -- "_�,_ , � .- � - - , - - `_ � � W. , . - - . 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