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Home My WebLink About1580DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -5 -22.21 BOX 15 01580 /1 U/ PiJ'Y'NAM COUNTY DEPARTMENT OF HEALTH . I�1V1S, IGN.O�' ENVIRONMENTAL- .:HE .L-T -H S:E�VICES ,,..:.:.:.:......_ .w.:... CERTIFICATE OF CONSTRUCTIONN COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # I —9 % Located atl! 7-- , V E 1 Town or Village Owner /Applicant Name APDLF_- r 1D6-E `I"1"F_'5 Tax Map Z" Block 5 Lot 2 Z • ) Formerly eA -H Mailing Address > KI DS-6 Subdivision Name cSl_- ul is 5Z' Subd. Lot # Date Construction Permit Issued by PCHD 15 14 1 Zip Separate Sewerage System built byS&Po1_& '9tPae- i oM.ES Address (5 5,4,Q0i..z✓ KtQgr-- Consisting of I 2-r';0 Gallon Septic Tank and 6 6-7 Lf:::� 2' W 1 Ox lylo �_H Other Requirements: Water Sup ®Yv: Public Supply From Address or: V, Private Supply Drilled by P� Address i C Tti, �Am sea__ � Bui�din T. _ e YP gl I� /1 l Wl m ed. Has -erosiowcortrol b&weo Number of Bedrooms Has garbage grinder been installed? N f� I certify that the system(s), as listed, serving the above premi es wer s d essentially as shown on the as- built plans (copies of which are attached), in accord e ' ued PCHD C nstruction Permit and approved plans and the standards, rules and the o ty Dep of Health. Date: 11 -7 Certified by P.E. Y,_ R.A. PyTNa*^ P X (Design P fes-S Address 102 GW Ns6lQA Am-_ e-,4,2 6L Uj) IbSIlLicense# OCy -7 =1W 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 sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available 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 Public Health Director, such revocation edification or change is necessary. By: New A2912 Title: 6041!C ?4�11 Date: d-( C1 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 m4m ;W E OF SUBSURFACE SE V11 AGE TREATMENT SYSTEM Owner or Purchaser of Buffi 9 1 l Building Typ _ Subdivbiun Lot � I represent that I am wholly and completely responsiblq, for location, Workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been .constructed as shown on the'approveil plane or approved 'ainihdrniht theneio, and in accordance with the standards , rules and r.e . gul a ns fthe Putnam County Department ofHealth , and herEby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any pain 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 Complian&' for the sewage treatment system, or any repairs made by me to such system, except ►here the failur' C td , i. _ _..:..�..._ ..... ®pPsv@ pr ®perIly i caused..by.the willful ®r negligent act ®f the occupant of the building utila�aa� tBat System. The undersigned further agrees to acc4pt as conclusive the determination of the Public Health. Director of the. Putnam County Department of Health as to whether or roof 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: Month Day Year 9 9 Signature: u- Ln= r 1 Title: V, P General Cornt- A — ar) o ature i qORTHEAST LABORATORY of DANBURY Formerl y Tarlton Environmental Laboratory) CT Cert: PH-0404 19-3 MILL PLAIN ROAD DANBURY,- CT . .06811 NY Cert: 11471 '(263) 748:79o3-,--FAx-(Y63' i4s= 66s2 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: P.F. BEAL & SONS INC. 4 PUTNAM AVENUE BREWSTER, N.Y. 10509 DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: DATE(S) TESTED: TESTED BY: REPORT DATE: 9/24/97 1:45 P.M. P. BEAL 9/24/97 9/24/97 LAE*.1471 9/26/97 SAMPLE SITE: SADDLE RIDGE DEV., LOT #1, SHAWE VALLEY EST., BRESTER, N.Y. SAMPLING POINT: HOSE BIB AT WATER TANK SOURCE: WELL-NEW TREATMENT: NONE TEST PERFORMED -RESULT: RECOMMENDED LIMIT' BACTERIAL: - Total Coliforin (Bacteria) 0 per 100 ml 0 per 100 ml CHEMISTRY: Chlorine Residual mg/L ----- ml = milliliter mg/L = milligrams per Liter ND = none detected RESULTS BASED ON SAMPLES SUBMITTED: 9/24/97 SAMPLE, AS TESTED ABOVE: MOTABLE or DOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) *BACTERIA SAMPLE COLLECTED IN SODIUM THIOSULFATE BOTTLE Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828-9787 - FAX (860)829-1050 TOLL FREE WITHIN CT: 800-826-0105 e OUTSIDE CT: 800-654-1230 " '10 WELL C;U1v1YLt'11U14 rZrUml DEPARTMENT OF HEALTH ..-,Division -Of-,Environmental PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET AOURESS: WN/VI / I.Y TAX GRID NUMBER: Ice Pond'Road, Lot #1, Shawe Val2ey Estates, Brewster, New York WELL OWNER NAME: ADDRESS: Saddle Ride Homes, Inc. 15 Saddle Ride Road, Holmes, NY 12531 ❑ PBIVATE ❑ PUBLIC USE OF WELL 1- primary 2 - secondary ® RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP Q ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING . ®REPLACE EXISTING SUPPLY TEST /OBSERVATION ADDITIONAL SUPPLY ®NEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 285 ft. STATIC WATER LEVEL 60 ft. DATE MEASURED 6/19/97 DRILLING EQUIPMENT ® ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH 41 fL MATERIALS: 0 STEEL O PLASTIC O OTHER LENGTH BELOW GRADE 40 ft. JOINTS: ❑ WELDED ® THREADED O OTHER DIAMETER 6 in. SEAL: W CEMENT GROUT O BENTONITE OOTHER WEIGHT PER FOOT 19 Ib. /ft. I DRIVE SHOE ® YES ❑ NO I LINER: OYES 10 NO SCREED DETAILS _ ._ r. _ _.. .. DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED? FIRST Q. YES. 0 N . -HOURS- SECOND. _ ... __....._:_.. _... .. .. -._ ._._ . - ........._ ...... _ - GRAVEL PACK O YES O NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH 'ft. BOTTOM DEPTH It. WELL YIELD TEST I If detailed pumping METHOD: O PUMPED i tests were done is in- tR COMPRESSED AIR , formation attached? O BAILED O OTHER ; ❑ YES [I NO WELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Rear- ing Well Dia- In FORMATION DESCRIPTION coot tt ft WELL DEPTH It. DURATION hr. min. DRAWDOWN ft. YIELD gpm. Surface 25 Drillirg in overburden clay and boulders 25 Hi ro k at 25' 285' 6 hr. 180' 25 25 41 Dr iling in rock, set casing, grouted 41 285 Dr Ili g in rock granite WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE Well Xtrol WX #250 CAPACITY GAI, 44 PUMP INFORMATION TYPE submersible CAPACITY 7�M MAKER Goulds DEPTH 200' MODEL 7GS05412 VOLTAGE 230 HP - WELL DRILLER NAME P.F. Beal & Sons, I C. 8/21 97 Aooaess 4 Putnam Avenue gIgp Brewster, NY 10509 J /69 Malcolm °T. Beal, Jr. /5\S MTKAM COUNTY DEPARTNE fI OF REALTH .. . Dhbkn d Enbensleiltal HeoMb Saevkm comet , N.Y. 115n oo Pswlde Peivlt g as CHRTBIWATE OF COM UM CCM CONS1 MOMIN FMW FOR SEWAGE DMOSAL RUM PA-[• SHA T V9 ;A6 dod' Town or 5V91W.. ... •..�r22 -�I:. (i) P A►MSl-v�i� R� ❑ ❑ / N.ee Dye of Previous Approvd Msfts AdbeM D Town Boduble T..51 tl& —t-r— V11 l.T Lat A. I V5 2 A c Fm Section poll LJ Depth volume Nit'ber d Resbo omoa - J_ Deng Flow G P D O D 1 PCHD Noftwdoo 4 Required When FM Is completed SOPMem Sewmv Sytitem to son" of !�cwh, Sop& Took tmA 67 Z 21 WIDE A(J S02 PRO rgerJ6 H To be eanatrntted by'b 15E Addm= Wader Snp*: Pd t Sw* Frog Aimee on , �_ae..r� SoM Dt®ed by R� VET . ��____ 1 rep►ewnt.that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate taw di sal s stem above dsaHled will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a repu ns o na County Department of Health, and that on completion. thereof a '.Certificate of Construction Compliance" satisfactory to the Commissioner of Meelthwill be submitted to the Department, and a written guarantee will be furnished the owner, his suceesm►s, heirs or assigns by the builder, that NW builder will Disco in good operating condition any pert of said sewagb disposal system during the ce loa of two (2) yeas Immediately following the date of the Issu- an of the approval of the Cortif)cato of Construction Compliance of the original or epeNS thereto; 2) that the drilled well deswMed above wHl be located as shows on the approved plan and that sold well will In to ce th t standards, rules and regu TEn of the Putnam County Department of Health. Date d T Signed ,.. P.E.. RA. Addresal�i.ITP1N��1 bZC?(F= /"� ��*'Yfl� Zie�inse No O10 APPROVED FOR CONSTRUCTION: This approval expires two y fr m the date issu nless construction of the building Ms been undertaken and is revocable for Ouse or nay be amended or modified when consid sory by. the issioner of Health. Any change or alteration of construction sequins a M l m AAprovW for disposal of domestic sari ag o► star supply only. Rev. AI 10 /88 Dae By Title 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 # P-� ~ Ni WELL LOCATION - Street Address Town/Village/City Tax Grid Number P 'J -_17_- WELL OWNER Name ailing Address �M 6NA b Wfj SkA6CM 1\j S Private 0 Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ® BUSINESS O FARM O TEST /OBSERVATION 00 INDUSTRIAL b INSTITUTIONAL O STAND -BY ® ABANDONED ® OTHER (specify, AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 16MEST. OF DAILY USAGE" gall O REPLACE EXISTING SUPPLY O TEST /OBSERVATION 12-ADDITIONAL SUPPLY IM SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE WDRILLED ODRIVEN ODUG OGRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF TELL IS LOCH ED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: '`C`, Lot No. Q WATER WELL CONTRACTOR: Name `� �� i � Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _,4 _NO MAKE OF PUBLIC WATER SUPPLY: /& TOWN /VIL /CITY -- DISTANCE T0. PROPERTY _FROM NEAREST WATER MAIN:, �Qk,eg- LOCATION SKETC& SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET (date) (sign e) 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 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 dril in oper ions be contained on this property and in suc"% a ,�aJnner as not to degrade or othe a co inate surface or groundwater. Date of Issue: G "Y -� 19 Date of Expiration 1713 19w- Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES __INDIVIDUAL_ WATER SUPPLY. & SUBS.URF.ACE. SEWAGE DISPOSAL. SYSTEMS _, ... ..._.. / REVIEW SHEET fo` CONSTRUCTION PERMIT STREET LOCATION 5 1J E A U Uf ` /'NAME OF OWNER f2 l� BY B. HEDGES R.MORRIS OTHER DATE .5' / g7TAX MAP # DOCUMENTS. Y t1 PERMIT APPLICATION Ell C -1 [e jrl�NGINEERS ELL PERMIT PWS LETTER [� AUTHORIZATION DESIGN DATA SHEET(DDS) RPORATE RESOLUTION S THREE SETS OUSE PLANS - TWO SETS [1 VARIANCE REQUEST E1�2_U SUBDIVISION DIVISION APPROVAL CHECKED ERC RATE/i IRED DEPTH — �CUI�I °SIN DRAIN REQUIRED =STANDPIPES MCP. AREA; SHOWN; GRAVITY FLOW, SUFF. SIZE 'rF PUMPED PIT & D BOX SHOWN & DETAILED OUSE - NO. OF BEDROOMS ELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM PROPERTY METES & BOUNDS �fiOUSE SETBACK NECESSARY (TIGHT LOT) OUSE SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE NO BENDS; MAX. BENDS 45° W /CLEANOUT FILL SYSTEMS YBARRIER . FT HORIZONTAL: SLOPE 3:1 TO GRADE ILL SPECS FILL NOTES FILL CERTIFICATION NOTE EPTH GAUGES ILL PROFILE & DIMENSIONS GENERAL lwL IN EXPANSION AREA APPROVAL SSDS ADJ. LOTS WT LAND ( TOWN/DEC PERMIT REQ ?) TRENCH �PiATA ON DDS PLANS & PERMIT SAME TRENCH PROVIDED X =60 FT MAX = PRE- 1969 - NEIGHBOR NOTIFIFICATION FARALLEL TO CONTOURS 0 %•EXPANSION PROVIDED ~ ..._ • . .... ......_........ a. = 100 YR. FLOOD ELEVATION SEPARATION DISTANCES SPECIFIED ON PLAN REQUIRED DETAILS ON PLANS VAGE SYSTEM PLAN - (NORTH ARROW) IS HYDRAULIC PROFILE = GRAVITY FLOW 4STRUCTION NOTES (GRINDER NOTE) }GN DATA: PERC AND DEEP RESULTS D -FOOT CONTOURS EXISTING & PROPOSED AY & SLOPES CUT AIN DRAINS [ON CONTROL; HOUSE,WELL, SSDS [ON CONTROL NOTE & DEEP HOLES LOCATED ENTATIVE OF PRIMARY AND EXPANSION TION MAP "'TO P.L., DRIVEWAY, LARGE TREES ,., S,,L.TOP OF FILL �G' TO FOUNDATION WALLS W 15' WELL TO P.L �00 TO WELL, 200' IN D.L.O.D., 150' PITS 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (PITS -20') 50' INTERMITTENT DRAINAGE COURSE 200 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS 15'MINTO C.D. S= >5 %,20'- 4 %,25'- 3%,30'- 2 %,35'- 1%,100' <1% 20' MIN TO C.D. DISHARGE /100' WITH 182 CONS DAY DIS. 10' FROM FOUNDATION; 50' TO WELL COMMENTS: PUTNAM ENGONEERING 102 Gieneids Avenue cCarmeh New York 1 0512 _ - 914 -22 Fan: 914- 225 -2955 Letter oT Tirans>r>r ittaa Date:.. (:::1 -7 Attention: RE: 15414 ,d —`/ r__ 9:z=i'A._r= Q'brlE ARE SENDING N®fll kAttached _ Under separate cover via the following items: Shop drawings _ Prints � Plans — Copy of letter _ Change order (ranoe_e Date No. — Samples _ Specifications Descrintion # THESE ARE TRANS -1411 TED as checked below: ")( " rora PP toval — A PP roved as-submttdd — Resubmit' — "_. co p ies"for -a PPfd,�al _ For your use _ Approved as noted _ Submit _ copies for distribution _ As requested _ Returned for corrections _ Return _ corrected prints For review and comment Other REMARKS: COPY TO SIGNED: . If enclosures are not as noted, kindly notify us at once. I ea • r1Al2,c4 221`'17 hhe_ -TH ! >6-°i 1- e,-:, . Af9L, Gtr: OF CeMPLL&, � ea . 09 L 'aDj `(i WeIL fteMtf !t2 l" �°,• JkAZl 5l-� THESE ARE TRANS -1411 TED as checked below: ")( " rora PP toval — A PP roved as-submttdd — Resubmit' — "_. co p ies"for -a PPfd,�al _ For your use _ Approved as noted _ Submit _ copies for distribution _ As requested _ Returned for corrections _ Return _ corrected prints For review and comment Other REMARKS: COPY TO SIGNED: . If enclosures are not as noted, kindly notify us at once. I Date— Re: Property of PAM '54AW Located at c HAW b�: (T) F,4 l%d Section 34-. Subdivision of Subdv. Lot # Filed Map Gentlemen: This letter is to authorize Block Lot 2'Z # 2 -70'Z. Date a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 14$ or 147, Education Law, tary Code. Countersigne P.E., R.A., # Address' Telephone is Health Law, and the Putnam County Sani- s Very truly yours, Signed a- 41 v Owner of Property • Address war- Ny Ic5c�� Town Telephone DESIGN DATA 5"=- SDSSMCE Sr'7qA Ct, DISPOSAL SYSTMi ME NO. DWner �1- {•�y�l �� y. s•T". Address D "� {� , NJV 1c�So� I.00rtea at cstreet) ICS �'ohd sere' Elocac S Trot 22 e (ird:.cato nearest. cross e,,se`t) - , c,: ► i ty Wat _z-shed G 7 SO=T PE-2C MA=CV MST LRIM ==ED M BE S W= APPLICA —TICNS bats of Pre -Sczki ng • 41 301 g 6 Date of Percolatica Test EOLE 251/-f 2`f 1 3® IdUAM-EM c= E 25 1/2 Z-f 314 PE',C ULT-11 CN Run Elapse Depth to Water Fran Wet-- Level No. Time Ground Surface In Inches Soil Rate Start -Stoo Sin. start Stop Droo In P'. zvla LxCO " inches Imc:es IT:Gt:es 2Ib-40 11:10 30 251/-f 2`f 1 3® 3 l I: I I P '.-1 50 25 1/2 Z-f 314 I '/4- 24 4 5 ... . D'� 12 10 :� 2 2 24 ar-) 23 3�4 2.'4 13.E 4 5 1 3' YJOTFSe . "..z :. fists to be repeat at s&Te depth until approximately equal soil rates are ebtaine3.at each percolation test hole. All data to•be submitted for review. 2- Depth measurements to be made from too of ho? e . . G.L. 21 31 "5&N1> � rv� 5' 6/ 71 8' gt - - 10' 11t 12' 1 13' IN -Dictum L= AT w -F—ias Cmmammr ; IS =rj-N=m - + Iii -DIC=7 -- L=E, M W "HIC w-A= LEVE , PJS- A . EELNG t-,-JM(JV=M DEEP fiCLE CBSERWICNS MADE BY: (yDT-GA , rlL.' -NYGDeej (31{'P4MODA =: 91Z,4`75 i5 DES lG Soil Rate Used Min/1" Drop: S.D. Usable Area Provided' 'No. of Bedroans Septic Tarn Capacity _gals. Tya Cie Absorption Area Provided BY Cow -1 L.F. x 24" width trench Other Name _ T j�„d1 I 14C,2 01459 1 !4G Signature Address Lae GL-6 (6(01A A SEA-r. G,A►�Ct -- �1 y lD�l2 ��, � � . . ys THIS SPACE FOR USE BY 8,...A H DEPAkD`21? -' CNLY: i��`�� Soil Rate Acorcved sq. f t /gal.. * Che--kei by . Date APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Flame and Address of Applicant: gKr--wsrF-- I?- I \ fosc>'� 2. Name of Project: ?� VAL±4�_r- -51-ATe.5 3. Location T /V /C: fA-5r_>,f-.J 4. ' Project Engineer: ��TNaGI�I;L�� 5. Address: 1 2G�rl fit% License Number: Phone: 225 "306>a 6. Tyae of Protect: Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) T. Is this project subject to State Environmental Quality Review (ScQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. _.90.Has DEIS been _completed -� and found acceptable by Lead Agency? ........... O 0. Name of Lead Agency �� _ '1. Is this project in an area under the control of local planning, toning, orother officials, ordinances? ........... .............................!5;. 2. If so, have plans been submitted to such authorities? ................... � IS. Has preliminary approval been granted by such authorities? . Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water —A—Ground Waters Ig. If surface water discharge, what is the stream class designation ?........ &G. Waters index number (surface) ......... ............................... .. 47. Is project located near a public water supply system? .................. ICI 18. If yes, name of water supply OA Distance to water supply) M 19. Is project site near a public sewage collection or disposal system ?..... rJo' 20. Name of sewage system N.. VJ Distance to sewage system 21. Date observed: 19 ! 2-O Icl S 23. Name of Health Inspector: E5IL1- I +ED665S- BOO o- �_Prni --* A 4-- flow (gallops per day)...... .. ............................. ' `25: Is�St te- PoPlutant Di- scharge =Elimination System: (SPD €.S )a= Pe-rmit.•.required?,. i - �`�� 26. Has SPDES Application been submitted to local DEC Office? ............... N /A ZT. Z8. 29. 30. 31. 2. Is any portion of this project located within a designated Town or State YES wetland? ................................... ...........•................... _ Wetland ID Number ........................ ............................... N 1A, Is Wetland Permit required? .............. ............................... w n Has application been made to Town or Local DEC Office? Ox& Does project require a DEC Stream Disturbance Permit? ................... 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 No 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 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? 35. Are any sewage disposal areas in excess of 15% slope? ..................... 36. Tax Map ID Number ......................... ............................... IT. . Approved Plans are to be returned to: Applicant X Engineer :f 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 )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 ny knowledge and belief. False statements made herein are punishable as a Class A H it dgmeanor pursdan t to Section 210.45 of the Penal Law. ;IGNATURES & OFFICIAL 1 (AILING ADDRESS: TITLES: FAI �es �i�7�S�M ► JA(� q IDS 6- L,6NEJ0A A ,/L APPENDIX C FINAL SITE INSPECTION DATE: Inspected by: STREET LOCAT I ONE ~1 A I L-Ak-= OWNER PERMIT # TM # OR SUED i V I S I ON LOT # "l/e? I. SEWAGE DISPOSAL AREA a. SDS area located as per approved b. Fill section - date of placement 2:1 barrier LGTH C. Natural soil not st d. Stone,brush,etc..Ar e. 100 ft. from water II SEWAGE DISPOSAL SYSTEM a. Septic tank size - b. Septic tank install c. 10' minimum from fo d. DISTRIBUTION BOX Room allowed for expansion, 100% - 1. All outlets at s Size of gravel 3/4 - 1;" diameter clea 2. Protected below Depth_ of gravel in trench 12" minimum_ 3. Minimum 2 ft. or ' from SDS area ds 250 - water tested e. JUNuTIUN BOX - properly set f. TRENCHES 1. Length required - Lent 2. Distance to watercourse measured 3. installed according to plan 4. Slope of trench acceptable 1/16 - 1/32 5. 10 feet from property line - 20 feet - 6. Depth.of trench < 30 inches from surfa 7. Room allowed for expansion, 100% - 8. Size of gravel 3/4 - 1;" diameter clea 9. Depth_ of gravel in trench 12" minimum_ -- - ''-l0 -. - Pie ends capped g. PUMP OR DOSE SYSTEMS 1. Size of pump chamber 2. Overflow tank 3. Alarm, visual /audio 4. Pump easily accessible manhole to grac 5. First box baffled 6. Cycle witnessed by Health Department estimated flow per cycle 111. HOUSE a. House located per approved plans b. Number of bedrooms IV. WELL a. Well located as per approved plans b. Distance from SDS area measured c. Casing 18" above grade___ d. Surface drainage around well acceptable V. OVERALL WORK MANSH I P a. Boxes properly grouted b. All pipes partially backfilled c. All pipes flush with inside of box d. Backfill material contains stones < 4" e. Curtain drain installed according to p' f. Curtain drain outfall protected & dir i g. Footing drains discharge away from SDS h. Surface water protection adequate i. Erosion control__ provided i YES I NO I COMMENTS G T_ 4 / • - I LOTA I.852 Ar,.± County Department of II8L U*A f environmental Health Services as noted for conformance with .o Euias and Regulations of the { n ty IIealth Departmen ^e '& Title ate r • 1 i f I AS -BUILT MEASUFEMFNTS (IN FEET ). - ertify that the sewage disposal system was ' d as indicated on this plan and that the system was by Putnam Engineering, P.L.L.G. before it was covered over. i was constructed in accordance with all standard -egulations of the Putnam Gounty Department of the New York State Department of Health. • consists of the Following gallon precast septic tonk,�1 l.f. of 24" wide absorption Iditionol regvirements I. 2 V 8 �i �0 12 gl� AT -72 1 12 79 �5 B g"7 114 0;612 813/2 1 -79l2 73/2 - ertify that the sewage disposal system was ' d as indicated on this plan and that the system was by Putnam Engineering, P.L.L.G. before it was covered over. i was constructed in accordance with all standard -egulations of the Putnam Gounty Department of the New York State Department of Health. • consists of the Following gallon precast septic tonk,�1 l.f. of 24" wide absorption Iditionol regvirements t 0 9 i