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HomeMy WebLinkAbout1457DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -45 BOX 13 01457 -� ; . 9% r , f r Vj • ,` 1• �, T ` �r r I Jr 01457 J 9111IM11119 TR.i�i.1 -. Area �_ oD� ��i -t sew oa vaime Nob Dealp. Flow G P D - 17PCBD NoMmillm In Requbed Wbm FM Is wylsted Map—,le Sawrte a s>m Ir $apUe Task ad --A� �- 4,9fj TmcP4 T.b.:owa4�cgd;b� W"- SEP*- - Pine SW*,Framl Address OtMa 1b�YMaaYa 1 represtnt'ahat I am wholly -arw conipletafy.responsible for the design and location of the proposed system(s); 11 that the separate pw di sal stem above described will be constructed as shown, on th Lpp►oved amendment there to and in accordance with.the standards, rules a regu ns o m County . Department of Mmkl , and that on completion thereof a ••Certificate of Construction Compliance^ satisfactory to the Commisoonef. of Heslthwill to tuOrnitted to .the Oepartnient, and a .written guarantee will 0e furnished the owns►, his auoaasors, MMS Or_ assigns by the bu{Wxr, thet said OYIWar will place in tldod diliGiO eg condltion "Y port of aid sni agS disposal system during the period of two (2) yews lnmedletely' following theslate.of the Iliew atlee of the approval Of the.Certif kato of Construction Compliance " -Of the ori/inel system or any repeirs thMeto; 2) that the drilled wail described a6we wall be located as shorn On the approved plea and that Yid wail will be inst 1 in accordance with the arlWr s, r Ns and rej aeons -of the Putnam County Department or Health. Oats 4,1- .: SNn P.E. R.A. Addre f IV license No ) 2A APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless Construction of the building has been undertaken and is ►eirOCaboo for cause or may be amended o► modified when considered necessary by the Commissioner of Health. Any change or alteration of construction requires a ew per t. Approved for dkootil of domestic sanitaryTIQMge; and /or private water supply only. By CW lh., yl DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #� ING REASON FOR DRILLING L WELL TYPE ®DRILLED ®DRIVEN ODUG O GRAVEL O OTHER I IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: VA' �`( Gill►�1�1U(��L�sS r _V r1., _ I 1 Gl WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ii NO NAME OF PUBLIC WATER SUPPLY: PI/A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED '®ON SEPARATE SHEET 2� (date) ( 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 thirt;• (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 Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health provided by the Putnam County Health Department During all well drilling operations, the applicant Street Address Village /City Tax Grid Number WELL LOCATION N1 � 051 to degrade or otherwise contaminate surface or groundwater. Name I Mailing Address GrPrivate WELL OWNER Vl� �2 Permit is Non - Transferrable 0Public USE OF WELL RESIDENTIAL 0 PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 ABANDONED ®- primary O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify 2- secondary 0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR El REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION. 12 ADDITIONAL SUPPLY ING REASON FOR DRILLING L WELL TYPE ®DRILLED ®DRIVEN ODUG O GRAVEL O OTHER I IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: VA' �`( Gill►�1�1U(��L�sS r _V r1., _ I 1 Gl WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ii NO NAME OF PUBLIC WATER SUPPLY: PI/A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED '®ON SEPARATE SHEET 2� (date) ( 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 thirt;• (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 Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health 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 suc h a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: 19_ Date ,of Expiration 19� Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner Well Driller 3/89 Yellow copy: Bldg. Insp. Orange copy: all- APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: • 9 �'7� �1 r71��,�U� . 2. Name of Project: �i2Ot�G�Ep[n 3.__._Location� /C: a��o 4. Project Engineer: H7,14zr- --f lk) w ef-�-DI —' T = 5. Address: License Number: + �TI 6. T e of Pro ect: Private /Residential Food.Service ....Commercial Apartments Institutional Mobile Home•Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State. Env _iron_me_ntal Quality Review (SEQR)? Type.Status (Check One) Type I`.. Exempt - Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? 9. Has DEIS been completed and found acceptable by Lead Agency? ......:.... 10. Kame of .Lead Agency ti. Is,this project in an area under the control of-local planning, zoning, or other officials, ordinances? ................... ................. T�— 12. If so, have plans been..submitted to such: author .s tie s ?....................... N 13. Has preliminary approval been 'granted by such authorities? Date Granted:_ 14. Type of Sewage Disposal: System Discharge...... Surface Water ✓ Ground Waters I5. If surface water discharge, what is the stream class designation ?........ :6. Waters index number (surface) . ..... , , , J. Is project located near a publi.c water supply system? 8. If yes, name of water supply WA Distance toy water supply 9. Is project site near a public sewage collection or disposal system ?..... i,1v ,0. Name of sewage system Q/A Distance to sewage system , t. Date observed: - • 23-._ -Name of Health Inspector -- rt y. Project design flow (gallons per day) ..................................... n _ 2. 1. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. X10 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? .................................. ............................... 1.�D 23. Wetland ID Number ............................... N4A 29. -Is Wetland Permit - required? .............. ............................... Has application been made to Town or Local DEC Office? .................. 1/� 4 30. Does project require a DEC Stream Disturbance Permit? ................... �1n— 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 tJ A- 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 K-M DESCRIBE: 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? ate N 35. Are any sewage disposal areas in excess of 15% slope? ........................ 36. Tax Map ID Number ...............:............. .,A, 37. Approved Plans are to'*be: returned to: ................ App-1 icant ✓ 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 maybe grounds for the rejection of any submission. I hereby affirm, under pena7ty 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 Pena 1 Lair. SIGNATURES & OFFICIAL TITLES: ,AILING ADDRESS: �*^ - i Rev 3186 PUTNAM COUNTY DEPARTMENT OF HEALTH i Divlelou of Envbronmental Hadth Serviced, Carmel; N Y10512 # ' /�, Engineer Mast Provide \� % P C H D Permit q ..T . TIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE, DISPOSAL SYSTEMj•D;�j . - o erne T" Map 4" _Block ' iZ G��! Located- Lot Owner /applicant :Name . i Formerly Subdivision Name Sabdy.,Lot N. _ yj�2 ✓1 r� Zip �% :. Date.Penmlt Issued Mailing Address:.. Separate Sewerage" System built " by � °t- S� X ` • �`ti , + ��� Address RIC Consisting of Tank ands —%� Water Supply: Pdbllc Supply From : Address or= : ✓ Private SapplY _DrWed by& e At%leeee GAT{ �T►1 a( �i Building Type ?fib c�s� :` Has Erosion Control Been CompletedY `�i� Number of Bedrooms Has Garbage Grinder Been InstagedY Other Regaicemente :. I certif that the s atem(s),as listed serving the above premises. were constructed easentially,as -shown on the plans of the completed work. {.copies Putnam Count' De ,rtment Of Health with the fled" lan, the'pemif 'issued by the of ahich;are, attached), and in.a`ccozdance with the standards rules and requ tions inaccordance r Oats �. (.: /........1./ . ,:; Cerhfled by P.E vR.A. Aad►ess Vi nse No. Any. person oeeupyiny;pnmises served Dy;the above: system(i) shall promptly take such action e's may be neoessary,toocure the•correction Of any unsanitary condition resulting from 'sueh. ussgs Approval of the separate sewerage system shall become null and void as soon as a pubs >:' sanitary savwr ,becomes avalNtile and •the approval. of the' private vvatar supply shall pecoms null and voW when a putilk "water supply bocomes wallabN. Such approvals are sublect to modification or change when; in the `judgment of the Commissioner of •Health, .wch. revocation, modification or change is naCasary. ' oate��' '— - �. °vy � '� Title 9 ANALYSIS DATA SHEET — _!3- "TYPE: PW LOCATION: Lot #19, Jenifer Ct., Patterson, NY REPORT TO: McGlasson Realty Inc. ADDRESS: PO Box 610 CITY, STATE, ZIP: Carmel, NY 10512 DATE COLLECTED: 10 -13 -93 TIME COLLECTED: 10:30 COLLECTED BY: Ted McGlasson REPORT DATE: 10 -15 -93 LAB # 93 -5226 SAMPLE SOURCE: Well Pump DATE ANALYSIS RESULT UNITS METHOD ANALYZED Total Coliform Absent /100mL SM17 (9215D) 10 -13 -93 THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER 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 a ,_Con low WELL CUMYLhT1ULV O Office Use Only 3/89 aas -3fgr� owner or Purchaser of Building �r. Building Constructed by � I,ocation - Street r uzicipal.ipty 1 Building Type 4 5 Section Block Lot FQi N S�- Sv � I PqS��� Subdivision Name C9 Subdivision Lot I C,UARAN= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I. represent that I am wholly and completely responsible for the 10cation, workmanship, material, construction and drainage of the sewage dispose. system serving the above described property, and that it has -been constructed as own on the approved plan or approved amendment thereto, and in accordance. "fih the standards, rules and regulations of the Putnam County Department, of Healtht and ,hereby guarantee to the owner, his successors, heirs or assigns, to place: iii; good operating condition any part of said system constructed by me whidh fails to operate for a period of two years imuediately following the date of sppro� =ak of the ...... "Certificate... of...Construction :Pompliance ",. for the sewage disposal systs,, or.any repairs made by me to such system, i em, except whore the failure to operate Properly is caused by the willful or negligent act of the occupant.of the buildini utilizing the system. .The undersigned further agrees to accept as conclusive the deter ation of the Director of the Division of Environmental -Health Services of the. PutnaJA County Department of Health as to whether or not the failure of the ten fiA o to was caused by the willful or negligent act of the occupant of building ilizing the system. Z Dated i of ay. 19_ Signature Title excel Contractor (Owner) - Signature McGlasson Realty Inc. Corporation Name (if Corp.) Rt. 6. Carmel,-N.Y rev. 9/85 mk McGlasson Realty Inc. Corporation Name (if Corp.) Rt. 6, Carmel N.Y. AcUress . 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