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HomeMy WebLinkAbout1570DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -5 -3 BOX 15 01570 0 x 'r'a't }L� ; -' ti N . •i` IN ■ ' 9 ' : I L ■ No 1 N I �' f , . 01570 PUTNAM COU ` i I' HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAQE-,2. $POSAL SYSTEM REPAIR fES NO' fithirnal Use Only. ­o9 Repair Permit issued in Last 5 years ❑ N0 4n 4n Watershed ❑ ❑� ,.Repair within Boyd's Comers, W. Branch or Cvoton Fab Res. � fa, Delegated ❑ � Repair within 200 tt. of a watercourse or DEC- maooed wetland C � r ❑Joint Review i SITE LOCATION as 410 TM # OWNER'S NAME 2 G' �/� � �� ( PHONE # MAILING ADDRESS / n t APPLICANT —? Name & Relationship p.e., owner, tenant contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED: INSTALLER PHONE # ADDRESS REGISTRATION /LICENSE# -� Proposal (include a separate sketch locating the, house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed trenches) NOTE: Repair must be in same location and of some type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE = TITLE Proposal aooroved with the following conditions! 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions.. Prop sal Approved �J Proposal Denied ) __ w� may. I soector's Signature & Title Date COPIES: White (PCHD); Yellow (Town'Bi); Pink (installer), Orange (Applicant) PC -RP 99ML DATE 17,/1' O Re 3/86 PUTNAM COUNTY ARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 Engineer Must Provide "P 4­3 --S 6 _ J P.C.H.D. Permit # OF Owner/ Ucant Name A0-r . r FOR SEWAGE DISPOSAL SYSTEM Town or V e 11 11 Tax Map '73 Block Lot s,�L i% Subdivision Name � A Subdv. Lot N Date Permit Issued .Separate Sewerage System built by �� � 1'75 �. C0 Address Z_06� 07rz ZZ Comelsting of Gallon Septic Tank and 691 L. Water Supply: Public Supply From Address ort X Private Supply Drilled by �1'1�� -t- Address 152EC -AS %EW ,tit/ ( 0TQ9 Building Type �%�—�" IOC t� e- Has Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been Installed? O Other Requirements I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work (copies of which are attached), and in accordance with the standards, rules and regul ons, in accordance ' h the filed plan, and the permit issued by the Putnam County D %epartm nt Of Health. Oats �'f �Z Z Certified ..A Z_ R.A. Any person occupying premises served by the above ,system(s) 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 null and void as soon as a pubt;: unitary ewer becomes avallatile and the approval of the private water supply shall.become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, In the judgment of the Commisglonor of Heal t such revocation, modification or change Is necessary, BY Title 1' Z. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF M71RO MEWAL HEALTH SERVICES Owner or Purchaser of Building Section Block Lot .s WIC-c,) NewelJ5 acv Building Constructed by Location - Street f4j-1"6esoal Municipality Building Type Subdivision Name o ! Al 0, J. Subdivision Lot I GUARANTEE 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 syste-,, 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- 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 determination o= 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 building utilizing the system. Dated this �Z.2, 'may of 19 �J?� Signature n Title eral tofitractor (Own ) -Signature Corporation Namb (if Corp.) 1 A 6 IT & ZZ- /?3 Ste. A/IY APM rev. 9/85 mk Corporation Xame (if Corp.) Add ess ELLIS A. TARLTON LABORATORY • DIVISION OF ELLIS A. TARLTON, ENGINEERS, INC. CHEMICAL 34 PLEASANT STREET DANBURY, CONN. 06813 -2328 WATER - WASTEWATER PHYSICAL METHODOLOGY BIOLOGICAL P O BOX 2328 203- 748 -7903 APHA - EPA - ASTM NAME AND ADDRESS OF PERSON TO RECEIVE REPORT REPORT OF BACTERIOLOGICAL AND CHEMICAL EXAMINATION OF WATER DATA Bart Campbell 1 Bullet Hole Road Patterson., NY SOURCE OF SAMPLE Water Supply, Campbell Res. 1 Bullet Hole Road Patterson, NY DATE OF COLLECTION April 18, 1992 COLLECTED BY B. Campbell Hydrogenion COLOR TURBIDITY ODOR CORROSION INDEX DISSOLVED SOLIDS Concentration LANGELIER (PM) RYZNAR NTU Mg /L Alkalinity as CaCO3 Fluoride (F) Bicarbonate Nitrite Mg /L Mg /L Mg /L NITROGEN Alkalinity as CaCO3 Chlorine Residual Carbonate CONSTITUENTS Nitrate fvg /L Mg /L .00 Mg /L AS Total Hardness Conductivity NITROGEN (N) as CaCO 3 Ammonia Mg /L Mg /L Micromohos /cm Mg /L Iron as Fe Mg /L Mg /L Chlorides os CL Mg /L Manganese as Mn Mg /L Mg /L Detergent as MBAS Mg /L Sulfate as SO4 Mg /L Mg /L The arithmetic mean of. all standard samples examined per month using the membrane filter technique shall, not exceed ... MEMBRANE FILTER TEST '- Me— colony'per"1oom1'.-'Coiitorm °colonies' peY"sMaldr'sNMold fi`hdi"ho1 ex ce`ed-9%50m1.•'4r=mf- "7/200m1; or'13 /500ml. ° """ — ColilormColonieslL00ML..._._._ in: (a) Two consecutive samples; (b) More than one standard sample when leis than 20 are examined per month: or (e) 0 More than five per cent of the samples when 20 or more are examined per month. AT THE TIME THE SAMPLE WAS SUBMITTEO: W11. The results of the analysis of this sample were satisfactory and met requirements for a potable water. F] 2. The results of the analysis of this sample were satisfactory for a potable water but certain of the chemical or physical constituents were high. These are as follows: 3. This sample was not satisfactory since it did not meet the bacterial requirements for potable water. The presence of organisms of the coliform group in a sample of potable water is undersirable end, while not necessarily indicating the presence of any disease - producing organisms, does indicate that such contamination might survive to the same extent. The presence of organisms of the coliform group may also indicate that the treatment was not adequate at the time the sample was collected. 4. This sample was unsatisfactory as a potable water because certain chemical or physical constituents were above acceptable limits. These are as follows: COMMENTS The bacterial analysis showed no organisms of the coliform group at the time the sample was collected which indicated the water potable. i .. 3 ' via WELL LOCATION WEB! UU1WLb11UN hZrUict Office Use Only DEPARTMENT„ OF HEALTH....... _ -- .. _..._._ _ , _ -- -•.- • - Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH SfAEcr AOURESS: 76WN/V1U)LC]UCI TAi GR10 HU1.fSM Bullet Hole Rd., Patterson, NY Lot 1.. WELL OWNER NAME: ADORESS: Heelan Realty & Development Route 6, Brewster, NY IRPUBLIC PBIVATE USE OF WELL . 1 - primary .. -" 2 - secondary 91 RESIDENTIAL . " ❑ PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP ❑ ABANDONED • O BUSINESS - ❑ FARM • - .-... ....... ❑ TEST /OBSERVATION ' ❑ OTHER (specify) O INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 / EST. OF DAILY USAGE 300 gal REASON FOR DRILLING Q NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY . _; ❑.TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 345 fL STATIC WATER LEVEL 3 5 ft. DATE MEASURED 6 18 8 7 DRILLING EQUIPMENT O ROTARY 67 COMPRESSED AIR PERCUSSION O DUG ❑. WELL POINT ❑ CABLE"PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING, ® OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH 90 ft MATERIALS: ® STEEL ❑ PLASTIC ' O OTHER CASING DETAILS LENGTH.BELOW GRADE 89 fL JOINTS: )[J WELDED ❑ THREADED O OTHER DIAMETER 6 in. SEAL: OcCEMENT GROUT ❑ BENTONITE OOTHER WEIGHT PER FOOT _ 2 Ib. /IL : :QRIVE SHOL4 Q YES ❑ NO LINER: O YES ONO _..._..S.EAEEN. - -:... DETAILS DIAMETER (in) -.SLOT SIZE LENGTH (11) " DEPTH TO SCREEN (ft) _ DEVELOPED7 FIRST O YES OHO SECOND HOURS GRAVEL PACK OYES O NO GRAVEL­ SIZE DIAMETER .: OF PACK in: TOP DEPTH tL BOTTOM DEPTH n. WELL YIELD TEST It detailed um in P P g METHOD: O PUMPED 1 tests were done is in- t 0 COMPRESSED AIR , ormation attached? O BAILED O OTHER O YES ' ❑ NO It more detailed form$tion descriptions or sieve analysts Y�Y ELL LOG � are available; 0.!C* attach. DEPTH FROM ' SURFACE : ", Walar Bar• I^9 wen- da> FDPkiAT10N DESCRIPTION t30C tL • L WELL DEPTH IL OURATION hr. min. DRAWOOWN n. YIELD 9Cm• Suruce An Gmy bard= 80 345 yes 6 Meidurn .to hard grey. granite 345 300 WATER ® CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS O COLORED ANALYZED? YES ONO ANALYSIS ATTACHED? M YES ONO _ STORAGE TANK: TYPE Tai ash ate, CAPACITY 62 GAL. 16 PUMP INFORMATION TYPE C +7 brain r s i }+T A CAPACITY „k,s Goulds DEPTH 259' :. 7EH07412 VOLTAGE 2-3-0 HP 3/4 WELL DRILLER NAME MILL DRILL NC . 116/87 A00 ESS Putnam Ave. � Brewster, NY e Dat�eafbablal 9 Cog" XlAiIS12- IN pswo 0 101tft M UWAM OMOSAL'SUnk Patterson Burdick Farm ANN wo", 73 5 8 Each SdWkMNg pedge, Bart Cam pbel n aofPiew Affmad 7114186 M a AA 'P. 0. 86k,, 386 Brewster, 7-,7NY.. "..Brewster. —24 10509 t. dbMM_ t1a Riihilivision' Annroved, Fee .Enclosed 13 Amrnmt ' was �M Re s i'deh ce . ht A ga"R.3_i Ono ft 2. FO S«11N ONO Li D" Voda, 'D goo PCHD liialrlatlu In Iteeinkrad Man M Is amokbd jiveninia smmnv $vogm 6 NNW 1250 MMjRiSdp*TgRk@w._ 67—ft. leh4th of fields elk a. 4 —Fame a** Fit" an Plifflile So* Ddbd by __-Adilress the I reterseent that I &M, w"lly W4 cGiffloway responsible for the dwgA-s';id local," 6 vvd—(i) 1 1) that the operate sew d{ al $"*M above ~Ibei will be'. - tructed as shown on the approved irnondnfent there to and in iccordfince with the slainclerds, rum and regulations or whe Putnam con CPAWY OMPSKSMANCof "Oak and that on Ion t4oreof 'a ­4C4rtificsis of construction C~i4vM*" satisfactory to the Commissioner of Hamhwiu 60 gAbWAtted to the DogrtetaM. and a written quarant" WIN, be- pumm" the owner, his aNxessaw,16 hews or assigns by the builder, that am builder will M atone .SpwNV4 com"aft.wif pert of aid saw period of two (a) Vows imene"tely following thellato of the Met- nigis d"I sVitun during the thareto; S) that the drilled well doacribod albon allied Of, she, ilagirliVill Of 40NO'CANtIfIC1140.4f COINAVAliti6n -C f 'WO go W@Md U WAws 00 "so approved Man and thet'said, W ulas and regulations of the INVIROM County Oapert ant of/"UKk. ►JE. N.A. Dow, P.O.. - BOX, 3 eW Na NY 105,09 051011. AWROVIED FOR CONSTOLCTIONI Thelablere"I *Morill. the: Anti issued -Uinmi,construction -of the building- has bean'unioruican and is nroeNIs for or MW In attended or ty"111411 who con iy by tin -cofflinissi4itii . of Health. Any change or afterstion Of construdion saw a disposal of private-water suppiv only. Revi.­ T 77 7-�L ci PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING;'.:CARMEh, . N. Y. ' . 1d51'2;: DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner KqViejj kdE A.T a� �� N 7 )) . a a? Located at (Street �, �(e�c. � Sec. Block s� Lot 'A tindicate nearest cross s r e Municipality — a- �,��� Watershed L:C�-M raj SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS o e Number CLOCK TIME PERCOLATION PERCOLATION Run apse Depth to Water Water Level No. Time From Ground Surface in Inches Soil Rate - Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches A 1 — Pro- Sow 4 - .. 2. �.4� -g� �g 30 3 �[.zo -q-So 30 16,S is.S 4 jQ•Z3- 10,,53 30 I6.a ($S z 15 5 i3 1 Pre SOCA — 2 (�� r __ 3 4 36 - iii Or. .30 r S 1 Q.1 S I17S 4 10,01 - 10.31 30 1h 5 (0'3S- 11:08 30 (7.1 l 3 . 4 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 SOUS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO.. I HOLE NO. 1 a HOLE NO. G.L. rmle Broiusn Pali- b -Awr 6 0ayn Sc 1211 v,,A Casi 1811 24" 5 li7 Glow l.n�w. plwt {1� d '34" 3011 1' e30" .30" 3611 ew G�� T�� 4211 �i( +, ^;1 r .0 I Si Ii Gig 100.% 48 661K i r pe, Olt C, 5411 11 66 X7211 ( S_ l_ u��_ s l _ a 811 rl'Z ✓ 0.rG� POr $4" mot% 92a, INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED - -- INDICATE: LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY .- J, '�, F. Date c{ DESIGN Soil Rate Used Min/1 "Drop: S.D. Usable Area Provided_ Q _ :m� No. of Bedrooms Septic Tank Capacity �7_S-0 Gals Absorption Area Prov ded By��'� L. F. x2411 ���tiw�ct c . . �. Name ' 2. Ei�ga mj cs Sign "e Address.--i>.©. S Lt TS"t�tS'1� 10 `yC' THIS SPACE FOR USE BY HEALTH DEPARTM, T ONLY: Soil Rate Approved Sq. Ft /Cal. Checked by —Date 9"f.(�\,,, �' fi l PUTNAM COUNTY DEPAR'IlMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL MATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS (Name of Owner) COMMENTS REVIEW SHEET,- CONSTRUCTION .PERMIT _ ._, • ,,. E : �--. DATE REVI . BY: (Str et Location) b'7 YFS NO DOCUMENTS Permit Application (� Corporate Resolution Plans - Three sets j (i Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions.- Volume D or J Box;Trench /Gallery; PLwV pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area .Expansion .Area; stlown; gravity- f low, suf f .. size., If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft, of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 110; Type pipe No Bends; Max. Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 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,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' from Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same 4G/ V Q%Jv;m� ti /c S8. JUNCTION BOX (TYP) BURDICK FARM LOT 41 AS BUILT PLAN SCALE: 1 ° =50' SCHEDULE OF. DISTANCESo FFtM4 A TO SEPTIC TANK INLET, 54' SEPTIC T4*"oun -ETv 88' FROM B TO SEPTIC TANK INLET SEPTIC TANK OUTLET �a �[7 Iva "S FROM B TO SEPTIC TANK INLET SEPTIC TANK OUTLET