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HomeMy WebLinkAbout1506DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -3 -48 BOX 14 M"6 !I IL I a L ;1 Iy - ■, 1 01506 Re. 3/ 6 -PUTNAM. COUNTY DEPARTMENT OF HEALTH Divlsioa of Environmental Health Servlcea, Carmel, N.Y .'10512 ` 5 Mast Pr o. ld A J g eer k� ' � S ermit �w P.C.H.D. P CE R ATE OF CONSTRUCTION COMPLIANCE FOR SEWAGEI MYOSAL'SYSTEM, _^ Town or Village ; Located at. l c–, .Tan Map clock 7 Lot —t. Vwner /applicant Name r � n�� T'/� Formerly Sabdlvielon Name Snbdv. Lot # Melling Address 'ref �{ It°�c tCr^ sii�a Ztp f 15�J4 Date Permlt,Issued _j�j 'Separate $ewe e S stem.bunt b ! �'�'- GC' 9�Tl� c i p Address Consisting of f Z CIO Gallon Septic Tank and L, F 4- i r YC - Water Supply: Public Supply From Address or: P_,rlvate. Supply Drilled by Address __f A=q t= l_._ Ba1lding Type –z�.11�BI�iCr as Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder. Been InstalledY .. Other Requirements I certify that the system(s) as listed serving the above,premises -tiers constructed essentially as shown on the.plans of the completed work ( copies of which are attached), and in accordance with the standards, 'rules anq.regu ti i, in accordance with filed plan, nd the permit issued by the Putnam Coun De rtment Of Health. `mil r �y / / —�'a-� Certd{sd by P.E. R.A. Date _..L /���1 Address License No. Any person'. occupying premises served by. the above systems) shaU'promptly-take such action as may ben wry to secure the correction of any. unsanitary conditions resulting from such usage. Approval 'of. the separate'sewsragd ,system shall become null and void as soon as a pub!'_ sanitary sever becomes available and the approval of the private water supply shall become null antl'yoi0 :wDen a public water supply becomes available. Such approvals are .subject to modification or change when, in the judgment -of. the Commissioner ofwtfealth, such rev tion, modification or change is necessary. Date v L T/. 9y�^ —� an "Y►- U WELL CONO'I,ETION REPORT y Off On DEPARTMENT`OF HEALTH- Q Q Division :Of Environmental Raalitl9:.SeYVices PIITNAM COUNTY AEPARTMENT�OF AEALTH ato tl STREET ADDRESS $A% G NUh18E • -• NA ,' ADDRESS:' IOS"O BIVATE WELL 0,1NNER r: O PUBLIC USE YdELL' I1ESIQENTIAL ❑ PUBLIC SUPPLY Q.,AIR /COND. /HEAT PUMP D ABANDONED 1 primary O BUSiNESS ❑ FARM D TEST /OBSERVATION D OTHER (specify) 2 secondary O;iNOUSTRIAL a7 I(�STITUTIONAL 0 STAND -BY O MOUNT:'OF USE YlE1.0 SOUGHT ; .:��.., gprn.tNO.: PEOPLE SERVED / EST. OF DAILY U5AGic ^. gal. . REASON FOR'= ;NEW SUPPLY , 0 PROVIDE ADDITIONAL SUPPLY D TEST /OBSERVATION DRILLING REPLACE EXiSTiNG.;SUPPLY ❑DEEPEN EXISTING WELL 'DEPTH DAI. - WELD DEPTH - fit. ':STATIC WATEALEV.EL .�� tt. DATE MEASURED DRIL1 iNG C1 PoTARY i� OMPRESSEI) AIR PERCUSSION. C7 DUG , QU1PNtENT'' "°Ca WELL a01NT © 'CAPL, -TERCUSSI01�'. f.7 OTHER (specify): dbl ��WELL TYPE... O ;SCREENED O.OPEiV'END CASING OPEN HOLE IN BEDROCK O OTHER TOTAL LEiVGTH 44:: rMATERiALS: STEEL O PLASTIC O OTHER CASI,�IG. LENGTH*- :BELOW:GRADE'� it = JOINTS: [7 WELDED I�?HREAOED O OTHER RETAILS DIAMETER .:.. -:iii. ,SEAL: t`EiVIENT GROUT D BENTONITE C] OTHER WEIGHT PER FOOT ... - abait:: DRIVE SHOE:RTES O NO LINER:OYESy�1V0 DiAMITER (inj 'SLOT S121 LENGTH (tt) .DEPTH TO SCREEN (Tt) DEVELOPED? scREl FIRST pETA1LS ® YES oNo `SECOND HOURS w.. ®YES GRAVtBL * DIAMETER TOP BOTT061 GRAVEL PACK O" o Izl::.. of PA CK: ,—. in.' OEM ._.._._..._tL DEPTH ...._.. It. It' more- detailed formation descriptions Or sleve-unalyses `USPELL'�IELfiTE$T It detailed, pumping SELL LOG are available, please attach. ME1H00 O PUMPED tests were done Is irI DEPTH °EROh+ weer weir COMPRESSED %IIR , formation•atxached� SURFACE eear Oia FORMATION DESCRIPTION cool: 01 BAiL0 ' D .OTHER ; 0 YES. O Nt7 hater. WEII.OEPTN Dum * °Z DRAWDOWN yilxlD Lana It . surface i t QUALITY %O CL,OyOY, NESS r ' 3 "co COLOAEp' gP�AI.Y t QYES,�;taND �. ANAt;Y ATT'ACttED'! O YES t7 N0 STORAGE. TANK TYPE ^ PUMP'IHF08MA710H`° CAPACITY _ GAL. TYPE R s C�PACt11f Wf:LL ORtUER NAM OA E 8, MAKER pEPiH :. M n,,._. c.C/1�✓ SiC MODEL dOLTAGE F;4 - 6 Owner or- urc aser o ED Building S� lding_.Constructed by Loca o - Street 'Municipality Building Type Section Block Lot gull CAc C� Subdivision Name Subdv. Lot # GUARANTEE OF SEPARATE SEWAGE 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 success - ors,..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 initial use of 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 occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determin- ation of the Director of the Division of Environmental Health Services of the.-Putnam County Department of Health as to whether or not the fail - Ure 'of' the' system 'to operafe -was - caused by the willful or, negligent- act of the occupant of the building utilizing the system. Dated this day of._ t 19 Signature ^--- Title CorpalGation Nam or . ) Address THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health couNTY.oF,i�rEaTCHESTi:R E 11 Rev. 88 DEPARTMENT, OF LA ®ORATORIES AND RESEA14CH . . VALHALLA :'NEW YORK 10595... BACT LION OF b,RINKING AND TREAT.EO.WATERS j a W Lab. No. W Bottle No. O l r Leb.tNo�ENt: ~ Date Coll'd Time Tlmet '' )" Time Submitted A ' Tests (Circle SPC, Coliform MPH, oliform A1fembrane. Fecal, Other Coll'd.by Agency Cotl'd for Coll'd from; Madill, .Address F If '91%M (St. 90.1 Icily. Tae ". Village) ILO Cone) t ty) " Identification of Source egl1r��Lf'� Sampling Point,within Promises :al(/ _ �r^a Refrigerated? Chlorinated? Yes 0 No 0 Free-mg /I. Total-Mg/l. pH RESULTS OF EXAMINATION OF WATER MPN /100 ml. Standard Plate Count • • 94D Bacteria. per ml. (48 hr.) Coliform Group Membrane Method /100 ml. Number Positive Tubes. Total Coliform Fecal Coliform Other These results Indicate' sample (was. was not) of Reported by: Date satisfactory sariitary quality when the sample was collected.: k Ii. IV. V. Vi. TION SITE INSPECTION TM # OR•SUBDIVISION LOT # :.0 Date --0 11 In ted ER /� A -k 10 io YE-C CCYiTS- 8giAGE--DISPOSAL-79ZE;�- -'---'-'- a. SDS area located as per approved plans b. Fill section - Date of placement 2:1 barrier, IGTH WIDTH AVG. DPTH c. Natural soil not stripped "-Y d. Stone, brush, etc., greater than 151 fran SDS area. e. 100 ft. fran water course/wetlands. SEWAGE DISPOSAL SYSTEM a. Septic tank size - 1,000 �1,250' b. Septic tank installed level C. 101 minimum fran foundation d. No 90' bends, cleanout within 10 ft. of 450 bend e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested 2. Protected below frost 3. Minimum 2 ft. original soil between box and trenches f. JUNCTION BOX --properly set g. TRENCHES 1. Length required Length installe&S Z' kAl- 2. Distance to waterco-&se measured- ft. 13. Installed according to plan .4. Distance center to center 5. Slope of trench acceptable 1/16 1/32 "/foot. 6. 10 feet fran property line - 20 feet - foundations .2. Depth of trench < 30 inches fran surface .8. Roan allowed for expansion, 50% 9. Size of gravel 3/4 - lf" diameter 11 ki IV- V 'iO. Depth of gravel in trench 12" minimun ll.' Pipe ends capped h. PUMP OR DOSE SYSTEMS 1. Size of pump chamber - - 2 -OV 67 r P-1 er%ec .3. Alarm, visual/audio .4. Runp easily accessible manhole to grade q .5. First box baffled .6. Cycle witnessed by Health Department 1.il-v estimated flow per cycle HOU!�E- . a. House located per approved plans. ,;5/-, V b. NmgDer of bedroans WELL - a. Well located as per approved plans b. Distance fran SDS area measured ft. 1 c. Casing 1811 above grade. I d. Surface drainage around well acceptable. OVERAIL WORKMASHIP a. Boxes properly grouted b. All pipes partially backfilled c. All pipes flush with inside of box d. Backfill material contains stones < 41' in diameter e. Curtain drain installed according to plan f. Curtain drain outfall protected & dir.to exist.watercourse -Eischarge 9- Footing drains away fran SDS area h. Surface water 2rotection adequate i. ros�ion control prEv'ided on slopes greater than 15%. -k 10 io place' in' 'good. 'operaUngl'contlrtion any pail of Said sewage .disposahsystem <duririq ance of the ,approval, of` the ;Ceirtdicate of Construc ion .0 Ornpliance:_eot the oiiginal wlif.be located as shown on the approved plan and that said well will be �nst in acci County Department of Health Date 6,M/86` - Signed Adtlress P,.0. Bbk; 37 APPROVED F.O CON RUCTION This approval,expves one year'fiom he : •te if revOCable foI ca 5@ Or' D @- aRlendetl 01 modified whenlcOOSldefed nOC@ }y: the requires a ew per l oved for`8isposal "'of'domisstic sanitary.3 nd /or Oate By tl,0 f'two`(2).yearsami... .1ely following thedateOf- the,issu n any repairs. thereto; 2) that the drilled well described above vith standard!. rules and regu a Ions of ,the Putnam. PE . _X R.A: JY 1.0.'5 0 9 �cense ivp 0 51011 L ass construction �of.'the building _has been undertaken and is Ooner. Of , ea/[ Any change, or alteration Of construction w e s IP Y 4 y.. AAMA Title ®/� I y Putnam County Department of Health Division of Environmental Sanitation "-`-00V0RXTE-'0WRER -kPFLI:CA­TT ON- -: FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health - In the matter of application for ------- -------- ------------------- — — — — — — — — — -- — — — — — represent that I am an officer or employee of the corporation and am authorized to act for having offices at_ le j ----------------------- / — — — — — — — — — Whose officers are ; President �a7me jzd5'e" —__ — — — — — — — and Xcffres) — — — — — — — — — — — — — FZ Vice-President an — -(flame and Ad dTe-" ss Secretary --- - - - - -- -- — — — — — ------ _- - --'Ynd Address) I (Name P1JTt4AM Treasurer — — P19J4 T; I ---------- - - - - -- -- (Name and Address). and that I am and will be-individually responsible for any or all acts of the corporation with respect to the approval requested and all.sub- sequent acts relating thereto. Sworn to before me this 13!' day Signed of 19F4 Title Notary Public Gv&-.�,, KoLOK NCKWY Pubil * - , NI-1. ( " �f Now y, )I K04 1� k C , "flod in r 1,649 co !) nfy T0,M) Lx)lac, 16�- Corporate Seal ikr cA f . . . . . . . . . . . �,Tmavm BERVI X -N. Y. 105-1 ByaTEm- d dr as Lot .13:Loqk me. COr ..M;eet 70 _,__wtershed 'TO W BMITTED WITH Al_ ?PI CAT121_4S PERO. MCOTIATION. er �IR, PTO n 0 wu er r Soil; Kato �ifie �; around Surfa6e Stop Drop. -in in - Inaba s' Min./Jo dro'O , g� Imdhe s Inches Inch" i�" 40, i 6 , R 16 P !.,;eI,. Pt PUTNAM 0 U T y DEPT. OF HEALTH • . . . . . . . . . ..... L5 ,°.at :.each. percolation test hole. a britt. data to .'du a :m t'h *: Dth,�, measurements o: e made f- from + fvp UAI 10e, IS. P !.,;eI,. PUTNAM 0 U T y DEPT. OF HEALTH Nqt: t a roximateli, equial zoli 0 ,°.at :.each. percolation test hole. a britt. data to .'du a :m t'h *: Dth,�, measurements o: e made f- from + fvp UAI P !.,;eI,. PUTNAM 0 U T y DEPT. OF HEALTH be • repeated at same depth until i es�r-Ve-. dbtaU4�d a roximateli, equial zoli 0 ,°.at :.each. percolation test hole. a britt. data to .'du a :m t'h *: Dth,�, measurements o: e made f- from + fvp UAI P !.,;eI,. Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION _.... _. � ... - _r.Ra -- ._+. ..a.. ..._. .... •.ate....... .. •... ... _r.a �.. ..•. _.r ..i - .,...n - ......r .._wry...... _.+ .. ..... .. a-. _. ..: .. ss...+._ �..- _..... ..�. a. s......._..w :r. � —�_. FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health - In the matter of application for I,_�Gt ►i — Kam- — — — — — — ------------------------ represent that I am an officer or employee of the corporation and am authorized to act for C,0 — — — — � — — (name of1� corporation) — - having offices at G le _j —�_ - - - - -- l — _ - - - -- Whose officers are President_,_ ____________ am�e sand Address)- Vice - President.__ G L�- �1!�c� ________ __ — -� ame and Address) �' Secretary __ _____ —_ ... _ _ _____ — _ — _ — ___ (Name and Address) Treasurer. (Name and Address) — — and that I am and will be individually responsible for any or all acts of the corporation with respect to the approval requested and all sub- sequent acts relating thereto. Sworn to before me this /3A day Signed -- -� of I, 19 Lam Notary Public ' 42,t wxok 6 / Titled Corporate Seal LOT 7 A, 3,veoc) LOT 8 1 ` 1 i Bli!dOk /3 69.13' Zo DI"Cljl tr' t m 0 pP�..o = 42G�►fo 5F� 0.9790 AGfL�S' =' .O 0� 0. O ��oo :ooh LOT /0 iw 0 0 0 0% rn i� p�y�riaF 4Hi� � oEEPAeEP � LOF7 C LOT 9 FIAAL $UBPrV,61QQ PLC PRE'VA4aP F'n,2 GLEA! B(�OicK FILED -AP A lO • ZIII FILED TOIc/A1- OF PA?rE?Sou PO TUAIM CO..; UY. ScALo 50 " /''IA cernr- : noklxi Iw71ca-rEC> PejZE.cIJ - W IJILV " T3b4T LA 14 mr_5V-I Z_En A, 9F-e.CV-(OU oL ACC TIOW ,ulS JiLNP--,I WAh PeE.PAeEa IL! ACLoeDA1..1C.E tilN -TC)-1 115 MAP IhAVIoLlCilCl:.i =SEcn Z.IJti. -%W- E: 45nLJG. GoCE. C macr{C.E Pb 15L E -MO' + c:9 -r iE WE341 °(OZV 3iATE- EDIT MOQ ADop,, D Bd"131E LEW voeV- �T1ZTE AhA nc- A.AMCl.! of Ldkl c.IWDE2c,eouuc , mss, = ALN,, aaoc:rc, !Aod jai LAmt> Sues, bey. 6AID cEf- nG1CA- r-o-Le7 • Lic5r - 614OUL1. ALL �k zEc.l AJA I IL4-1 OWLq qr-) -ME- FeZ<,C>J GlaE k1LIQ4( _Wr-- Amc. 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E �' �r f 1 . -. .. •h jj a.� <,,i�' it.��$�F rl r.,r'f"'r�4 • �•I>til� t �'''�''�' 1 I ru 1 y (7/(`�>i..: fir" > ;{ +1 y � ,y,��i c r •. - >.r� r' (AT.r1 it• aPi} mit r' „r>2''"t u Jr`i'F''`"M1i��'iJl'G Q �T ttt,r IS J:E oomamm; 't:NDfio 'w• /11Qq'lMel�i�.1r`tii 1� a[;r`a1� - h�ciFri�11 � � BEING EN.6UN Tkg �FE ;T } E Date re, f1Q R Hwy , _, r 1 .I t i ' i 1 1 oil'a rte vie jd Mtn/1 "Drop: S.D. Usable Area. Pr ovided No: off:: Eedrooms SetiO Tank. Caaaity i2 Ab$orption Area•. roV s Sy„ = :•�- lr.P'. got a -nat �. Addre$a SE! THIS -: -ACE -FOR. USE 'BY HEALTH DEPARTMT ONLY: ,•; +'r'oi]:iate . Approved Sq. Ft /oa1 • Chocked •.I.'' ;rir';� ; it y • =.. .JAiiM} ae4Yvl)f�i4:a: iG.(:f. la {t: .. t.