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HomeMy WebLinkAbout1701DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -22 BOX 15 01701 Separate;Sewerage,Sysiem bailf•by Conslsting of Water Supplyi . Public Supply From Address or: ✓ Private Supply Drllled by 1 M)6 - dreas Bullding Type f72�/-T/ _Has Erosion Control Been Completed? Number. of Bedrooms Has Garbage Grinder Been Installed? • Other Re qulrementa I certify that the system(s).ias listed serving the above premises.4ere of which are attached) , and in accordance with the,'sfandaids, rules 'and Putnam County Depar entxr� Health. Date 1- �- Certified by. as as shown on the plVed n of the completed :work ( copies in accordance with the n, and the permit issued by the P.E. ' R.A. Any person occupying premises servedby the above system(s), shal(promptly take :such action as may be nscesury to secure the correction of any unsanitary conditions resulting from . such usage. Approval' of the separate'sewerage:syi6M shall become null and void as boon as a pub(:: unitary sewer becomes availathe snd the approval of the private' water :supply shall: become null and veil when a public water supply becomes availsbW Such approvals are sub)ect to _modification or change when, in* Judgment .of tlie'Commissloner of' Healtq, revocation, modification m change Is necessary. Date f2::e�j� ��15 By � � ----mac Title 1 I . a ,Putnam County Department of Health Division of Environmental. Sanitation AFFIDAVIT CORPORATE OWNER APPLICATION . _ FOR PERMIT. APPLICATION SUBMITTED TO PUTNAM £OURTY }[EALTH DEPARTMENT ! :� T0: Commissioner of Health - In the matter of application for represent that I am an officer or employee of the corporation and arrr authoraied: to act for�t� (name of corporation) s having offices at y_a �_ oJ_? Whose- officers -are Presidentp S }f C ,L0000,�-� �,[ reE� ame and-Address_) Vice - President (o G�c t}vi7/ -' (NRme and Address) _ _ _ ^ . Secretary �� 1 C- o G — � --:9t_ —/ _ _ (Name and Address) Treasurer _ _ (Name- and Address) P and that I am and will be individually responsible for any or all :act¢ • of the corporation with•respect to the approval r quested and all•sub- sequent acts arelatin' •theretoo' Sworn to before me this / � day Signed � _ _ _ _ � _ _ . _ of 198 Title otary Public ANNE B. COhRiDAN way sw�at *W Y* �r ContnisN�, my Wrelr?� is . ReA Nn =e71 tM887439 up�qr=4� Pew Corporate. Seal 9 j WELL COMPLETION REPORT Office Use .Only DEPARTMENT OF HEALTH a. Division Of Environmental Health Services w O PUTNAM COUNTY f DEPARTMENT OF HEALTH STREET'ADDRESS: wNlVl / Y W'GRIO NUMSEP WELL LOCATION Steinbeck Estates, Farm — — rket Rd., Patterson NY NAME:, ADDRESS: PBIVATE WELL OWNER MONROE HEIGHTS DEVELOPMENT CORP., PO BOX 970, CARMEL,NY ❑PUBLIC USE OF WELL KKR ESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND.IHEAT PUMP ❑ ABANDONED 1- primary O BUSINESS O FARM ❑ TEST /OBSERVATION .0 OTHER (specify) 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 - 5 / EST. OF DAILY USAGE 500 gal REASON FOR RkNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY D TEST /OBSERVATION DRILLING O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA ' WELD DEPTH. 700 ft. STATIC WATER LEVEL 2 5 ft.1 DATE MEASURED 6/17/88_ DRILLING ❑ ROTARY x9r-COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. MOPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH 100 ft. MATERIALS: x® STEEL O PLASTIC O OTHER CASING LENGTH.BELOW GRADE 99 ft- JOINTS: O WELDED x® THREADED ❑ OTHER DETAILS DIAMETER 6 in. SEAL: tiCEMENT GROUT O BENTONITE ❑ OTHER WEIGHT PER FOOT 19 lb./ft. DRIVE SHOE EMES ONO LINER: O YES ONO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (f t) DEVELOPED? :... DETAILS FIRST O YES ONO GRAVEL PACK O YES GRAVEL DIAMETER 70P BOTTOM O NO SIZE 11 ' OF PACK fn. DEPTH ft. DEPTH 1t: . TEST pumping Yy �L� LOG ft more detailed formation descriptions or sieve analyses WELL YIELD If detailed are available, please attach. METHOD: O PUMPED i tests were done is in- DEPTH FROM water Well Q COMPRESSED AIR r formation attached? SURFACE Dear- Dia- meter FORMATION DESCRIPTION cooE, O OTHER OYES -ONO ft., BAILED it Ing I WELL DEPTH DURATION DRAWOOWN YIELD Surface 90 HARDPAN & BOULDERS it. hr, min. ft, gpm. 90 200 M DILM TO HARD GREY GRANITE- 400 1 30 400 1 200 375 PINK & GREY GRANITE 600 2 15 600 1 375 580 BLACK & GREY GRANITE 700 6 - 500 5 580 700 GREY & PINK GRANITE WATEit XG CLEAR TEMP. QUALITY O CLOUDY HARDNESS _. O COLORED ANALYZED? =WES ONO ANALYSIS ATTACHED? WES O NO STORAGE TANK: TYPE Diaphragm PUMP INFORMATION CAPACITY 82 GAL. 26 TYPE s sible CAPACITY 5 WELL DRILLER NAME MILL DRILL C A 20/88 MAKER GOULDS - DEPTH 460 ADDRESS Putnam Avenue SIG MODE L7PW,041 - VOLTAGE210 HP 1._ Brewster, NY R bert i , es en �26�sri�TAL Building Type GUARA= 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 shoran 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 . Complianc:e° ,for. the...sewr_ age -dis sal. 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 of the Director of the Division of Environinntal 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. A .1 _ W Da this day of --1- 19 OO Signature 7 i _ .� _ _ - -,93e_ O _A Title + (Owner) - 1 ca Corporation Nam (if Corp.) _P0. 13Dv- cam" MAFZ, rev. 9/85 mk l l��- 1I aril! III + ELLIS A. TARLTON LABORATORY • " DIVISION OF ELLIS A. TARLTON, ENGINEERS, INC. CHEMICAL 34 PLEASANT STREET DANBURY, CONN. 06813 -2328 PHYSICAL BIOLOGICAL P.O. BOX 2328 203 - 748 -7903 WATER - WASTEWATER METHODOLOGY APHA - EPA - ASTM NAME AND COLOR --1 SOURCE OF SAMPLE Water Supply ADDRESS OF ' Mill Drilling Inc . Concentration Stelnbeck Estates PERSON. TO Brewster, N.Y. 10509 RECEIVE Putman Avenue f-: Lot #5 REPORT Brewster. N.Y- 10509 DATE OF COLLECTION 7/22/88 DATA COLLECTED BY Mill Drilling, Inc. Hydrogen Ion COLOR TURBIDITY ODOR CORROSION INDEX DISSOLVED SOLIDS Concentration LANGELIER (pH) RYZNAR NTU Mg /L Alkalinity as CaCO3 Fluoride (F) Bicarbonate Nitrite Mg /L Mg /L Mg /L Alkalinity as CaCO3 Chlorine Residual NITROGEN Carbonate CONSTITUENTS Nitrate Mg /L Mg /L 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 as 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 one - colony •por 100ml. - Coliform• colonies- per-standard sample shall not exceed 3/50ml, 4 /100nfl- 7/200fi1, or 13/500m1" "` Collform Colonies /100ML in: (a) Two consecutive samples; (b) More than one standard sample when less than 20 are examined per month; or (c) More than five per cent of the samples when 20 or more are examined per month. 0 AT THE TIME THE SAMPLE WAS SUBMITTED: 1. The results of the analysis of Phis 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: 1 D3. 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 and, 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. D4. 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 indicates the water potable. Certified 69&. ..........X„I.l._.:C...... ........... .................� ".`.�T.�`:�]/ Fi--,,� IL. A Q ✓� FINIAL SITE LNSPE'CTICV Date Ins ctei by ;CAT: �0�1� ° `�4 fi OR S'JEDIVISICN LOT a S ^i[?GE DISPOSAL A -MA j j —= b. Fill se --ticn - Date of placenent - ---- c. Natural soil not stripred I I -- d_ Stone, brus:, etc. , greater than 15' from SDS area. e. 100 ft. from wet er course /wetlands. S��u -- DISPOSAL, , SYSTU4 a. Seotic tank size - 1,000 1,250 b. Sentic tank irst=lled level I I I c. 10' mini= f=cn foundation I I d. No 90° bends, cleancut within 10 f`.. of 450 bend I I e. D I STRIEL'IICti EC-X !—.All out! ets at, same elevation - water tested , ,h ' 2. Protect--- �c:a frost I I I 3. M- nim= 2 -- origins soil between box and t`nc-!es E . JUNCTION ECX -- prcrerly set I I I I 1. Lena�`h r _r=te - - - 2. Dist :Pace tC war zccurse measur u 3. Ins=�ler acrdinc to plan 4 Distance canter to canter I i it 5. Slone car trench acce-o le 1 /1'0 - 1/32 " /acct. I I I 6. 10 feet f_ -a Drcre- --L,7 line - 20 f� t - foundati cns I 7. Dertn cr `nc.-� < 30 Lnches fran surface 8. Roan allcxad for exr�nsicn, 503 I °. Size of c _t;el 3/4 - 11" diameter 10. Dept* or c =vel in trench 12" m�-nimun I 11. Pi re ends cpced �. PD. -T.OR -DOSE S-�ST��S .1. Size of c�= mina - - 2. Overflow tank I I I 3. Ala=, vis- ca 4 Pump east =; accessible manhole to grade 5. First box 6. Cvcle wit,e=sed by Health De�rtment I I I estimates =1cW Cvcie 1 IV. H CL. b. �;�-ri of beer �.s V. iEEL a. Well local as rer approved plans b. Distance fr=, SIDS area meassred ft. c. Casing 18" aLcve grade. d. Surface drair=_ce around well accentabie. VI. _ OVERALL WCPJCLm- HTZ �. Ecxes procer_v grouted b. A? i pines .fir ti ally bac1cfilled c. pipes flue^, with inside of box c. Fackfill material contains stones < 4" in diameter. e. Certain drain installed actordinq to plan L Certain drain cut*all protected & dir. to exist.waterc c. Footing drai:^s crscharce away from SDS area 1. Surface water protection adeouate E__os.ion crnz: provi d� on slopes greater t`z ri 77777-77� 7, TUTNAMA on CERMCAM OF CO / place, in g8�d.-6,peritirig' co-iniflill6n .'any -part -of sa.d-sawa son.'Co or Date Iddrss- sl Date y " system(s); 1) that the separate sawage,disposal system x6rdance with the standards, rules and regulations of the Putnam his successors. heirs or assiI by.'the �uildei, that' said buiideir Will License No ny change or Alteration of c2nstruction i VS11 /I Title ~ V" •. DEPARTMENT -OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3.641 APPLICATION TO CONSTRUCT A WATER WELL �%g.1�� PCHD PERMIT OP-17-0 WELL LOCATION Street Address o Village City Tax Grid Number WELL OWNER Name P owe'45 PaSRG Mailing Address P. 0 r Co. M-Pfivate O Public SE OF WELL - primary 2 - secondary UKUSIDENTIAL O BUSINESS ® INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION D INSTITUTIONAL O STAND -BY ® ABANDONED O OTHER (specify 0 AMOUNT OF USE YIELD SOUGHT c�j gpm /# PEOPLE SERVED /EST. OF DAILY USAGEj,,)DQgal REASON FOR DRILLING MEW SUPPLY O PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE &DRILLED DRIVEN ODUG ®GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES L,"" NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 5zlFu& c- y Ri u_., Lot No. WATER WELL CONTRACTOR: Name '5 Qs -Q'eff_H i &IC-0 Address IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWNIVIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �-A& LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED, ON REAR OF THIS APPLICATION 5 N SE ARA SHE fty Na AIL-, 0,_s�fignAt-ULCI ture) 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 pro i e y P t unty Health Depar nt. Date of Issue: 19 Date of Expiration: 19 ermlt Issuing fic a Permit is Non - Transferrable White copy: H.D. File Yellow copy:., Building Inspector Pink Copy: Owner __ 2 87 Orancra mnv< WAl l nri l l ar am, APPENDIX Pumm aX=Y DEPAR24ENT OF REALM - DIVISION OF EfflnMENML BEAM SERVICES INDIVIDUAL MM SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSva (Name of Owner) REVIEW SHEET - CONSTRUCTION PERMIT DiUE ( Street Location) DOCUMENTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc.Hole Depth W� s/s (3) House Plans - Two sets Well ✓ permit; PWS lett Variance Request ' GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wet-land (Tcwn/DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flora Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder notes) Design Data: perc.and deep results Two-Foot Contdurs misting &'Proposed Driveway & Slopes Cut Footing/Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shcwn;gravity flow,suff. size ,If Pumped Pit & D Box Shawn & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systems Property Metes & Bounds . House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEP -WTION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fill 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expa.n) 15' to Drains - Curtain, Leader, Footing 351to catch basin, stormdrain, piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' from Foundation; 50' to well 15' Well to PL \ �S 60)( --rw 5$ l..F. bpsy�P T1aJ acs \sz� 1�OpE�TY Ltt.16 AriO -•TVFbGZI�F�V- ltClat, i�.iFO�t- td-rr,�r..l -rA>_/Et.J �SCp►.t :SU$otvt5tot.1 PLAT ` of �sr�u,JgE� HILL >= ILEt7 OtiJ AUG" S-r 3t 148 1 &S M,S.P t ,Mfit N'i k)