Loading...
HomeMy WebLinkAbout1642DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34.13 -1 -54 BOX 15 lelffo'� ,NEE R, MUSfi' rH PROVIDE _ n- -� X12 PERMIT `# Town or Village. ••_ 'LOtatetl at ', �� .: - - T'aii'1�fap / ! - �B16C Owner •� t IC / Formerly `J Tax Map Lot N . ��,Suba 'Lot y _Z n.iy lU�ca�s/✓ Z f�x�h T �Si Separate Sewerage. System' built by Address reD Consisting of 000 oal .,Septic ,Tank and 310: 4FY:Zy kllnr':' �+3.f'D OAi Tai '•+tJ(��cFt '.i i . i / t1 Other requirements o . ' • -pN LL ` nd 1. ! - :Y Water Supply , - Public Supply From T Private Supply ;grilled By ©„ ]�l •� , / �/ Add►BSs��✓ SOX' 8ulldinq '.Type `r �� / � � `NO ` of slid' oms Date Permit Issued AD °_41 Has. Erosion Control Been Completed? Y.e S Has, garbage grinder been installed?__�® I certify that_the systems) as (listed serving. the above premises_ were constructed essentially as, shown of the 'completed work ( copies of which are attached) an& in accoidance with the standards; rules. and ._regulations', -iw accordancR with the filed plan, and .the: permit issued by the Putnam -County.DepartmentOf,Health f. Date Z ` ' i,. Certified by P.E. R.A. T— Address ° v' Z Licenie No. Any person occupying' premises s, rved by the above system(i) shall promptly tike such fiction as may be necessary to secure the correction of any. unsanitary conditions resulting from such usage ilpp ► oval. of thee: separate sewerage ystem, shall became null, and void a$ soon as . a' public 'sanitary sewer becomes avafiable .antl the approval', of the,, private water supply shall become null and,,.'vofd, w 'an a public water wpply, beeonies available Sueh approvals are subject io modif.icatlon "or change when,' in, '.the judgment; 'of ,the'Commissfoner of• lealth, such' i' ocatiora; modification or change' is necessary. Date e� „ ! i . / // gT Title Rev. 6/85 a] zoa-_-k _-10-N.,� ------ DEPARTMENT OF HEALTH Division.Of Environmental..Health Services. PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION WELL OWNER nWN1VlW[A1CllY S1 ET ADDRESS. W'GRIO NUMBEit: rl V147 -e,__rrn V; ADDRESS: NAME: 45JBIVATE V jar 1161 4 , , , 0 PUBLIC /I A/ Ah ZffAJ / -P 17ZP PJ Mj—.. /,, � r A USE OF WELL 1 - primary 2 - secondary Oq RESIDENTIAL 0 PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED O - BUSINESS 0 FARM 0 TEST/OBSERVATION ❑ OTHER (specify) C1 INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY .0 AMOUNT OF USE YIELD SOUGHT — gpm./NO. PEOPLE SERVED --a-1 EST. OF DAILY USAGE8d ,5' gal. REASON FOR DRILLING— NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION 0 REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 0—C-42 ft. STATIC WATER LEVEL -i'o— ft. DATE MEASURED ® s-lzw DRILLING EQUIPMENT . ❑ ROTARY ,COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE 0 SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK 0 OTHER TOTAL LENGTH 31 ft. MATERIALS: ❑ PLASTIC 0 OTHER CASING DETAILS LENGTH.BELOW GRADE 30 fL _xSTEEL JOINTS: OWELDED D(THREADED OOTHER 10 in. SEAL: 0 CEMENT GROUT ❑ BENIONITE OTHER -DIAMETER WEIGHT PER FOOT Ib./fL I DRIVE SHOE: 0 YES NO 1. LINER: OYES ONO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH To SCREEN (ft) . DEVELOPED? FIRST 0 YES ONO HOURS SECOND GRAVEL I PACK* ❑ YES ❑ NO GRAVEL SIZE. DIAMETER OF PACK In. TOR DEPTH _ft. BOTTOM DEPTH _ it. WELL YIELD TEST If detailed um in METHOD: ❑ PUMPED tests weir. done Ass, 'COMPRESSED AIR formation attached? . 0 NO 0 8AILIfD 0 OTHER 0 YES WELL LOG `a`re;ovr`aidetailed formation descriptions or sieve analyses please attach. DEPT FROM SURFACE rots 'Water Bear• ing Well Dia- Meier In FORMATION DESCRIFnox COCE. It. it. WELL DEPTH ft. DURATION hr. min. DRAWDOWN ft. YIELD La6d Surface 17) U o 0 WATEII '&CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? DYES ONO ANALYSIS ATTACHED? IR YES ONO STORAGE TANK: TYPE6Je LC -A lVo L, CAPACITY GAL WELL 0 ADDRESS 5101MRE ME * 1fi PUMP IMFORMATION TYPE �mergj 1-19 CAPACITY ;4 I MAKER . DEPTH f - MOOELI-61-- VOLTAG HP 8L,_ _j Yorktown Medical Laboratory, Inc. 321 Kear Street LAB N;_ - _ Yorktown Heights, N. Y. 10598 Collection Station Used': Carmel Peekskill Director: Albert H. Padovani M: T.'(ASCP) Mt . K sc o New C i t.y r Date Taken: NOON Date Received: la- -t- 48ty lk 11 Date Reported: j.} °fs' - ;R Collected Referred By: J Sampl ce: -- LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA _ Fecal Streptococcus per 100 ml MOST PROBABLE NUMBER TECHNIQUE (MPN) Total Coliform: MPN- -Index per 100 ml Fecal'Coliform: MPN Index per 100 ml OTHER ANALYSES THESE.RESULTS INDICATE THAT THE WATER SAMPLE. (WAS (WAS-NOT) (NOT APPLICABLE) OF A SATISFACTORY SANITARY QUALITY ACCORDING T NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Albert H. Padovani., Wt. (ASCP), Director LEGEND RDS = Recommend Disinfect - ing Water Source < = less than TNTC = Too Numerous Too Count t� /\ Standard Plate Count per 1.0 ml (Agar plate @ 35 °C) MEMBRANE FILTRATION TECHNIQUE (MFT) %\.Total Coliform Der 100 ml lJ Fecal Coliform Der 100 ml _ Fecal Streptococcus per 100 ml MOST PROBABLE NUMBER TECHNIQUE (MPN) Total Coliform: MPN- -Index per 100 ml Fecal'Coliform: MPN Index per 100 ml OTHER ANALYSES THESE.RESULTS INDICATE THAT THE WATER SAMPLE. (WAS (WAS-NOT) (NOT APPLICABLE) OF A SATISFACTORY SANITARY QUALITY ACCORDING T NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Albert H. Padovani., Wt. (ASCP), Director LEGEND RDS = Recommend Disinfect - ing Water Source < = less than TNTC = Too Numerous Too Count DEPARTMENT OF HEALTH _ Division Of Environmental Huth Services /� W TWO COUNTY CENTER — CARMEL, N.Y..10512 (914) 225 -3641 . ........ ... APPLICATION TO CONSTRUCT A WATER WELL IELL LOCATION STREEI ADDRESS. � iUWNiV1LLAGE1C11Y IAX GRW NUMBER. � � � r1l NAME. • _ ADDRESS: '� WELL OYlNER c� ; 1&-PSIVATL 1) PUBLIC J USE OF WELL VSESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 1 - primary ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) 2 - secondary 'Cl INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY C-11 VIOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR O EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION DRILLING 1 ❑ HEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING. WELL WELL TYPE I g'- GRILLED DRIVEN E] DUG E] GRAVEL OTHER :S WELL SITE SUBJECT TO FLOODING? YES _NO :F WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: LOT NO LATER WELL CONTRACTOR: Name ��,� %j Address: _A,Pj7yfv/< /Z` .S PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO FAME OF PUBLIC-WATER SUPPLY: - TOWN /V /C IISTANCE TO PROPERTY FROM N•EARCST. WATER .MAIN OCATION SKETCH & SOURCES OF CONTAMINATION. 4:�" I _ (date) 4 7 (signature -- PERMIT T. 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: to 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. Date of Issue: Zi 19e)� P it Issu'' g Official Permit is Non- Transferrable PUTNAM COLUEY DEPARTMENT OF HEALTH DIVISION OF ENVIRONM=AL HEALTH SERVICES N ) ? Z tIzI Owner or Purchaser of B#lding Section Block Lot Building Constructed by Location - Street Municipality Building Type Subdivision Name 3� -%- � Z 5e-c- 7 7 Subdivision Lot # •Z ' GUARAN'T'EE 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 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 deternnination of the Director of the Division of Environinental 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 day of 19 Co Signature Title CvI ^NNS -` _ eral Contractor (Owner) - Signature Corporation Name (if Corp.) Corporation Name (if Corp.) Address Address rev. 9/85 mk -- — 3— — — r _ �y �,�TNAi C®iJ1�1TV" DEPARTMENT �� ������ ENGINEER TO PROOF , OMPLIA # l ealthiService3- Carmel N'Y. 10512 - .'PERMITT FICA. OF COMPLIANCE ypl _ Division of Environmeni'a H CONST:RUC710N PERNAIY FOR SEWAGE DISPOSAL SVSYERA .g Town�or �Ilage n Ldcated' %tom 7 �i� S� ��•� i ?ax Map s Block : U Lot �0 R -Ce.3a �� �' 6ubd :Lot q : Renewal Q Revisidri [] - ... pp Owner /Address ®�k� ;eVa 3 �.� Ld%I'�ses2�rQ_- Date,Of Previods Approval Building Lot Area '�`.� " Fill Section Only ❑ Number of Bedrooms 'Design Flow G /P /D^ �' P.C. H: D Notificatioo,Required 77- 777 Separate Sewerage System -to consist of ® ®� Gal Septic Tank;; and �0 To be Constructed by Address $� Water Supply: Public Supply From 7. Pnvate,;5upply to be driiled by A� Address Other' Requvements pia �a3�l� L „® I represent that 1 am wholly and completely responsible for the design, and location of the proposed,_system(s); -1) that the separate sewage, disposal• system -atiove descr�b'ed will be constructed:as show,nonthe�approved amendment thereto and in accordance vr�4hahe standards, rules an regu a �ons(o e Putnam, County 'Department of ,Health, =and that on completwn thereof a t:ertificate:,ot Construction Compliance satisfactoryto the Commis ;loner of Health will,' be :s. ubmitted to''1he• D.e par tment,'and a wir�tten guarantee will be� furnished -the owner his successors fieirsor' assigns by `the builder that saidb'uiltler will ... ;place in good operating.'condition any part of Paid sewage disposal' system' during..the.period of ,two (2) years Immediately_followmg ; tfiedate , of the issu ante oVthe approval,of..;the Certificate :of Construction Compliance of the „original system or,,. any - repairs thereto,2) that the drilled' well described above , will be locbted'as shosamorithe approved plan`and thaf_sai6well will be'Installed' m accordance, with the standards rules an-d. rsgu_a ions of the.,"Putnam' County Department of Health ' Date -�.. 21 �wh 5i9 / P.E. R.A. netl:' Address J APPROVED FOR CONSTRUCTION:. Tt revocative for -cause or,may be amended -c requires a. new permit:- Approved "for < q r� Date I: Rev 6/85 dified,when,consii sal of domesTV By %' License -No .T �' ear`from the date it id unless construction ;ot the building has been undertaken and.'is ed- necessary_.by the Commis ' r. of Health. Any change or alteration of- construction to sewage, and /or pn a wale supply only. Title 'PUTNAM COUN'T'Y DEPARIMM OF.HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL MTER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS FIELD INSPECTION REPORT INSP. BY: (Name of Owner) (Street Location) INITIAL SITE INSPECTION YES NOI COMMER S Wetlands on /or proximate to property .............. Property lines or corners found ................... Canestimate house location ....................... Willdriveway need cut ............................ Must trees be removed - note these ................ Deep holes representative of entire SDS area...... Additional deep holes needed....... ... .... Sufficient SDS area available considering driveway cut, house location, separation distances,etc... Adjacent wells/ septics ............................ D.H. - Deep Hole G.W. - Groundwater D.H. 1 Lot D.H. 2 Lot D.H. 3 Lot Depth to G.W. Depth to G. W. Depth to G. W. Depth to rock Depth to rock Depth to rock 0 ft. Soil Descri tion 0 ft. YES NO COMMENTS House SSDS, located per approved plan I......... Length of trench measured 3 ft. � width of trench average 3 ft. Slope of tile line and trench acceptable......... �CT 6 ft. Room allowed for expansion trenches .............. 6 ft. Over 100 ft. from watercourse .................... Natural soil not stripped or SDS area 1 unnecessarly graded ............................ 9 ft. -�' . 9 ft. 10 ft. maintained from property line and 20 ft. from house.... ...................... Distance well to SSDS (ft.) ...................... Numberof bedroans checks ........................ 12 ft. ^.y 12 ft. Soil Descr 0 ft.. 3 ft. 6 ft. 9 ft. 12 ft. Soil Descri t . [11 DATE: FINAL SITE INSPECTION INSP.BY: YES NO COMMENTS House SSDS, located per approved plan I......... Length of trench measured width of trench average Slope of tile line and trench acceptable......... Room allowed for expansion trenches .............. Over 100 ft. from watercourse .................... Natural soil not stripped or SDS area unnecessarly graded ............................ 10 ft. maintained from property line and 20 ft. from house.... ...................... Distance well to SSDS (ft.) ...................... Numberof bedroans checks ........................ Stones, brush, stumps, rubble, etc., greater than 15 ft. from nearest trench ................ AL 15 ft. of peripheral soil horizontally from trench.... ........ ... .4. ....... �e ka5 a C� r ���s✓�,. Boxes properly set......... ................... Could surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does-lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE.. ... r C.•-: I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BU!' ING., CARMEL, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner /J/LS'AddressZr Lejl fy& -�q,r) /9d -sue Located at (Street Sec. Block 1 Lot r'Z indicate neares cross s Feet Municipalit Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole.,. Number CLOCK TIME PERCOLATION PERCOLATION Run No'. 'Start Elapse Time -Stop Min.. 'Depth to Water Water.Level From Ground Surface in Inches Start Stop. Drop in Inches Inches Inches Soil Rate Min. /in drop 2 /d : Q % /Q `2_T -/ 2 Z7 5 = � i z: y2 �� 6Y Z.y z� Z� aio {owes 4 ti 4 DFp�. OF 'COU14 % Y H 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 OT{: SOILS 1,NCOUNTERED IN TEST_:HOLES:. = DEPTH HOLE NO. it HOLE NO.& HOLE NO. G.L. 6" 12" _ 18" 4" Ci y 24 t' 30" 36" 42" 48" 5411. 60" 6611 72„ 8411 N� Y INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED '�AQ°tC _._.:.__. - INDICATE "LEVEL "TOW CH WATER . RISES AFTER -BEING" ENCOUNTERED _....._. TESTS MADE BY dG(�',¢ L.IG� Date V- Zc(46r DESIGN Soil Rate Used Ddn/l "Drop: S.D. Usable Area Provided J*Ooo No. of Bedrooms 3 Septic Tank Capacity /Coo Gals. Type Absorption Area Prov ded By�L. F. x24' ,r%`— jb'— width trench. o �,Ier A d l3 �L c. , V 0 C 3� / i 5°® ?�2�o�I � ��'f}� < �0 �,r o Address gna c . THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Cal. Checked by 4 4 0. 041t to c m Z rm .lira S.aA. s� LE ENO \ M �BPrC ?,lNr O 4541 � �22EEPIY6�E - - Q il/E!L i i N SZB 00 ' {�S- (JLI/.L1T Y/.NENSIONS r dj 9 r L' 3 � y 39!0 y5 -O• lleE!/= 2.348�eES �2 /. Ser.toes�o vesOYSM -.77n /vsnl 7b CeWfo.ew 7n SRr+G /F/GTiaNS /�II5 Sell AiCTA' t9Y 7,mp Pe/rN.oN/ �rwryiyEACiN _ - �lOMlsr►aP..vl 2 ,t%VFOVWAW &Wrrw /O'..R5.50.A.. i �Q 3. T+�,we�vs sic. vEOrro f++ea�w�e= OF /LE r.�cc0o7�ie.Yu70o f/O•P/ZON7AL VALE /'Z� fNO Eq�iynsouN6 <L Cays7XC�7/oN //E.eTL^9L k �vsEx NYS' s emu/ C - /Fh'c,C CgNJ7.LflTiON e�TNe!SY:JTln 17' G' 4- iavr.f4e"C 7o iNSr -Ittii ,sEVfc .7a .crawl i BY e.�Ui7Y. zo o � Gorl3 3. �cc ciJrvS 7a .sri�o iC'.veo� ✓E ' 6. �4v' eo Lei 6LiNG. r✓�� >.9 9fFiN.�G RNr� J. NrLJEN i9.6YNtf o.B�'T /. \ 4'O/,0.derl THIS IS TO CEnTI1Y TIIAT THE SEWAGE DISPOSAL_ SYSTM .ScoAV ;b-A� fa,.r i ' "'•" ^RT -iD ON THIS PIaAN AND THAT 'a WAS O,yS.,�. ;_ :.,. .� THE - . -.. cOn? IT WAS COVER - tiaoG•�eeew _ T-D IN ACCO ?DPHCE OF THE PtiICIAM OZ. TY D'--' W .rr- .aase..wr r•u Lrlam Uuuncy Depai�imeuc ui healzL \ Z' rtvisi r on of 1';nvital health Service as sE�T�c oEsiGrV :r�re r0nm0r, noted for conformance with \ `Lo n -cable Rules and Regulatio of the atnam Cowity Health Department. �- ' 'f ?natura A T1 'S� I TOkW of P.4lTE.PSO/V - P!/TNAML�Ir/NTY -NEk/ yO,e,C �,�,,�� ofir Kem r� AS- 6011.'r No✓ z7, 1964 �' � 1 j�XESrvoeto eY # /I/ /GG /,pM F. ZE /GE.P ��tr/ivrc Eewe..sit f'U.✓o .i^uet�YS.0 G � w4 �.wurto Psvo /l7tw9►e NY /054/ `�y �O• i� ts�� (9r4) GZe9,4764 �FO °ROrrasloa� � r., i •f a . i SCALE. I"- ?-C>' C-PNTC:`UR INTERVAL - V i to DRIVE'' I V t 7 im 0 ol 150 r LL) 0 jeoFO4a8v WP-Ll- —jQ00 GAL SEPiTTC = K DISTRIBUTI — WAA"t- 475 y.