HomeMy WebLinkAbout1702DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
35. -4 -23
BOX 15
01702
y„
9L
L,
,
. ..
01702
-,x c. 3�z ^7..rpwy.'^ 'f'"''°4'• ^.s: T `3c:r- T, rFrF"eL'G•ri s rlr',q*fi -'-v --n I • O
m
PUTNAM COUNTY DEPARTMENT OF HEALTH
a _
REV . 3 86 ro . Divlsloh' f Environmental HeWtb Services, Carmel, N:Y 10512 `
a :En'gineer Mast Provide c c�
Cik AR's. nF CONSTRUCTION COMPLIANCE FOR. SEWAGE DISPOSAL SYSTEM
Owner /pppllcant N
Malling'Addrese -
•Y
-472 Tax Mapsl Lot
3 Formerly Stibdivislon Name LV . SnQbdv. Lot q
Zip / !/! �.. Date Permlt Issued v
.Separate Sewerage• System ballt'byONIC -y f %i %%- �CV �L ( LT%7Address 110 , I ✓0 l.J d, f �� /)T/4
Consisting of JCU Gallon Septic Tank and d & fi- &S �QI'/ �� ' WCA)61�
Water Supply: public Supply From Address �1,
or: ' Private Supply Drilled by. l U� ��G� LL �) 4dtdfrees r %TJIi Avg, 0/ L%S V� M
Building Type Hue Erosion:Contiel Been Completed? / �5
Nttmber of Bed Hue Garbage,Griader Bee n Installed?
Other Requirements
I certify that the syetem(s) is..listed serving the above premises were constructed essentially as shown on the p s of the completed,work ( copies
of which are'attached),'and in accordance wth'the standards, rgles` and regal eibns, in accordance w the fil d pl and the permit issued by the
Putnam County Depa iment of th. V//
Oats / � r1 Con if led by l P.E. R.A.
Address V WE Q"" / leena No.
Any person occupying premises served by; the above systems) shall promptly tak0,such action as may be necessary tosecure the correction of any unsanitary
conditions - resulting from such usage. Approval 'of the. separate seweiageisystam ihall becpine null'and void as soon as a pubs :sanitary siwer becomes
available Ad.-the approval of ;the, p-rivato watei'auliply shall become;hull and'vold:,when a` public" Watar supply becomes availabla.. Such approvals are
subject t�Naon hahg e wh en, in the)udgment of theConimisioner of .Health; su revoeatiori, modifieation or ehanga h rncassa►y.
Date �J G— is
Date ��
tij 0�
WDJjij LPa11VL4 L\LJL %JL%L
DEPARTMENT OF HEALTH
grtal.= HPalfin_Serviw.s
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
IWELLLOCATION
STREET ADDRESS: wNlVl / 1 Y TAX GRID NUMBEri:
Steinbeck Estates, Farm -to- Market Rd.., .Patterson, NY Lot 6
WELL OWNER
NAME: ADDRESS:
Monroe Heights Development Corp., PO Box 970, Carmel,NY
PRIVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
PRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND.JHEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT S gpm. 1N0. PEOPLE SERVED -3. to�5 / EST. OF DAILY USAGE 500 gal'.
REASON FOR
DRILLING
UNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
-30-5 DEPTH 3 0 5 ft.
STATIC WATER LEVEL 2 0 ft.
DATE MEASURED 6/14/88
DRILLING
EQUIPMENT
❑ ROTARY x1RkCOMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING, x9kOPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH . 71 ft.
MATERIALS: xgMTEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE 70 fL
JOINTS: ❑ WELDED IcTHREADED ❑ OTHER
DETAILS
DIAMETER 6 in.
S EAL:)a CEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT
PER FOOT 19 Ib. /ft.
I DRIVE SHOE OYES ❑ NO
LINER: ❑ YES ❑ NO
SCREEN
SCREEN
G.
DIAMETER (in)
7SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST -
—
- ❑ Y* ES.- O NO- ......
-a _
SECOND
_...
_ _. __....._,.
Fi0UH5 `- ._. ..._ _
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED tests were done is in-
92xCOMPRESSED AIR , formation attached?
O BAILEO O OTHER ; ❑YES ONO
It more detailed formation descriptions or sieve analyses
WELL LAG are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
Well
O'3-
mete
FORMATION DESCRIPTION
cooE_
ft.
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
9cm•
Surface
60
Hardpan ou
& blders '
60
3.05
Medium to hard granite
200
1 -
200
2 -1/4
305
6
250.
25
WATER � CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? XWES ONO
ANALYSIS ATTACHED?XQ .YES O NO
STORAGE TANK: TYPE di a hr� ate_
CAPACITY 82 GAL. 26
WELL DRILLER NAME MILL DRILLI , NC . DATE
ADDRESS SIG- R 7/20/88
Putnam Ave. o
Brewster, NY
R ert M. M1 1,' esident
PUMP INFORMATION
TYPE spbm nible CAPACITY . 0
MAKER _ids DEPTH 200.
10EJ07412 30 3/4
MODEL VOLTAGE' HP
e 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
NAME AND
ADDRESS OF
PERSON TO
RECEIVE
REPORT
WATER - WASTEWATER
METHODOLOGY
APHA - EPA - ASTM
a -r• w �_ .'. _. .�. .�
KtrOk i 'vi= is �ti:. i r:r�ivLOGi�.f+: NU Ci iMICAL t� iiAi ivr Oi= iiR7ti�
Mill Drilling Inc.
Putnam Avpnup
Brewster, N.Y. 10509
DATA
SOURCE OF SAMPLE Water Supply
Steinbeck Estates
Brewster, N.Y. ,
Lot #6
DATE OF COLLECTION 7/22/88
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
NITROGEN
Alkalinity as CaCO 3
Chlorine Residual
Carbonate
CONSTITUENTS
Nitrate
Mg /L
Mg /L
Mg /L
AS
Total Hardness
Conductivity
NITROGEN (N)
as CaCO 3
Ammonia
Mg /L
Mg /L
Mlcromohos /cm
Mg /L
I 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 par- 100n1. Coliform colonies per standard sample stall not -exceed 3/50ml, 4i100ml, 7/200ml. or .3 /SOOmI coliform 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 this sample were satisfactory and met requirements for a potable water.
0 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 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.
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 sainple was collected which indicates the water potable.
r /
PUTNAM COUNTY DEPAPMMU OF HEALIH
-.. D- TWMION :. -OF ENcIIRO r FiFALT VHS - -
a665�- r�� rs 7��u�rr�r gym.
Owner or Purchaser of.Building-
illDA)aDv1�- d r6+T5 T%VCL,0 762L)T OW, L-M •
Building Constructed by
ALL
Location — Street
Municipality
Building Type
Subdivision Lot #
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 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
I'rert.i " -Lcate of _.(;�nstructi4n Compliance "...tar. the.._sewage dist�osal..syste. 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 Environirnntal 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 o,. the building utilizing
the system.
B
117 this day of 19
• Signaturej
Title
t
Corporation Name . ..
'T LO ,-./a
rev. 9/85
mk
II.
IV_
V.
VT.
FINAL SITE LySPE'CTICN Date '7/-z o hr
•;CAT: rON
° 1-4 �/• �/ TM a OR _- ';[MDIVISICN lOr 4
a .
pr
_.. _ _.�.. .... _ _ ._ ._�; �..... w - r...._....:
- =...1r IVIi�..K....'.........
- .mac.
Sr AMA DISPOSAL P REA
a. Si,S area lccatr as per approved 21ans
i
b.
Fiil section - Date of placement
2:1 barrier. Iii wit�TH AVG. DPT -H
c.
Tctural soil nct strirmed
d_
Steve, bnusch, etc_, creates than 15' fran SDS area_
e_
100 ft. fran water course /wetlands.
S vfC DI-SPOSIAL, SYSTEM
a. Sentic tan'.•, size - 1,000 1,250
I
y
b.
Sentic tank installed level
c..
10' ndn mian fraa foundation
d.
No 90° bends, cl er=rcut within 10 ft. of 45° bird
e.
DISTRIBL'TICti BOX
1. All out! et= at same elev ti on - wGC-er tes=ted
-BOOS:
2. Protect- below frost
I
3. Mil i ui 2 f-. cricrinal soil between box and trEhc ^es
f.
JUNCTION KX -- prcrerly set
g.
2' S ' i
1 LehcLh L-_c°`h ins—L---"e^
2. Distance to wate_rccurse measix u ft.
3. InstaL =—,�` acccrdinc to plan
(✓r,
-
I.
4 Distancs csnt�r to canter
5. S' cre cf t_ nch accen_table 1 /16 - 1/32 " /foot.
_
I
6. 11,0, f=ete f_an prcre_ri,r line - 20 feat - four_Eaticns
I
I
7. De'JLh C.1 l -anc_h < 30 inches gram surface
I
'
8. Rcan al? ched for exr_ansicn, 50%
I
i)
1. Size of ca=ve 3/4 - 1V' ' diameter
10. Depth of =ve> in trench 12" miniman
11. Pi re E,ar c Iced
h.
Pr,_-rp OR- Das-E -s!=, -5
lm Size of Uum C'1c7i1'L`�r '
2. Ove-rflca t: Ek
3. Alamn, vis-c ` /audio
AV 04A",Q
a pap ersi i v accessible manhole to grade,
5. First box oaf =led
I
6. Cycle wit_.esSed by Health Demart-n ent
I
I
estimat =1C%q c,7cle
HOUSE
a. Ecuse lcx~tw r—c-- annroved plans.
I
b.
NL -tug of beer oars
I I
I
YT4 dA
a_
a .
Well local e-az as per anDroved plans
I
b.
Distance fr=' SDS area rne?sured f t.
c.
Casing 18" above crade_
d.
S'. -rlace dra, race around well acceptable.
OValMllb WORMMIA.SH— z
a. fixes 2rocerly crcuted
b.
Ati> pines martially backfilled
I
J/
c.
A:L! pines flush with inside of box
d.
Backfill rrtte_ri all contains stones < a" in diameter
l
e.
O Lain drain installed accordi.nq to plan
I
I
I/
t)
E-
0-1-tain drain cutfall protected & dir. to exist.wa.terccurs�
9_
Fcatinq drains disc'iarce awav frcxn SIDS area-
h.
Surface wata_r Prot =mien adequate
-
i.
E..=osion cyriLOi provided on slopes greater t'�ah 15 %.
1
I
—
I
PUTNAM COUNTY HEALTH DEPART
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of
INSPECTION
NAME Orig. Routine
G� c _ Orig. Complain
ADDRESS -/ �/� t°c `7 �%�� �/ _ Orig. Request
No. Street Town TM No. _ Compliance
Complaint Comp
MAILING ADDRESS Final
P.O. Box Post Office Zip.Code _ Group Illness
Construction
c Reinspection
PERSON IN CHARGE �� F' , Sampling Only
OR INTERVIEWED / / �` � � 'iel Conference
Name and Ti
,-/ Other
DATE "Z `� TYPE F LITY
TIME ARRIVED % < TIME LEFT Explain
FINDINGS:
?o
%1
INSPECTOR:
ULU
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
{
\\�s1•i 1. � l jj i'f - L } 3 !�` ,r.
p�TNAM COiJ NTY DEPARTMENT OF
to Peovlde Peemlt M
h u , F OF CO
Division of Fbvkonments! HeaN6 Servkea..Carmel N.Y 1061?
CONSTRII , ON PERM[r FOSsSEWAPEDLSPOSAL SYSTEM _
own or
S6bdivlaton Nnme STF /%✓.QEGk. /�I� ~T� �t} Blocb Z
f
�Sad>Id ;Lot M � Alt'. I � l
APP
anew RevieMn ' ❑
. ' b. Prevloae ro '-
f� n Date of val • ` �
Address / f' Town- ZIP
Mailing ....,., ............ .. ...__. ,.... ,
C
BaUding Type ��S /Q�CE lot Ares' 7 AG FM Section Only y Depth, r Vdttme
Nditi i Bedroome
Design Flow G P D YCHD NOW— w le Required Wben FS le completed
t ,i.. BoYckj. Lf A.dsa.�T/ Div' Tc.0 %! a
Soparate Sewerage System to�eottelst of :GaU�Sep— Tank and
Tn be ooust vdW by Address
Aaiwm
taster S _
oPPh P�Uc Sapply'From
. ors�Ptivtte SoDP�I'.De1Ued by �� /� � - Address `S
Other Regairemente r
1 represent hat I am wholly anQ, completely responsible for „the despn and location of "the +,proposed systems) 1) .that the rseparate "sews a ,disposil'.iystem
above descr�Uetl will bt ±,constructed si shown On the aDDroved amendment there, to and m accordance with the standards rules,a regu a ions of. ' e u nam
County Oepartmerit'of Hsalth and that on�comQlehon thereof a Certificate' of ConstiuctlontComDhancs satisfactory to 'the Commissioner of Health N'
b subm�ttsd to the; +Department and a'' wntten 'yuarantee will De furnished the owner hrs wccesiors, heirs or assigns;by the builCer; that safd, buHdfr wilt•
l .
plate' in yooq oDeraUrtg condition any ;part of Vseid sewage disposal system °dunng the period; of two.(2) years_ImrneAfitely fdllowirq the date of the itsu-
f
anee: qof th• approval. of the Cartifipte�;ot ;Construet,on':Compliencer o -t *-or, yinal, system or�any replin heieto 2) that the'diilled.well , desttfiaeA spow ,• . , ' e
will bs located as shown on the_approved. plan aneltMt said well will iii, 11 m accordance with the sta art's ru ano repu a IT�Ions of; the Putnam
County Department of Health L/
Oats; �Z /Z7 /7 j /J' S�9ned` PE_/ RA
7�fA���t�� /ter✓/ /� G�/ License
Atldress � �• i
APPROVED FORYCONSTRUCTION This approval. expires ` two years from the "date.. issuetl u esf construCGOn'Of `the building has'been undertaken and is
reJO`uDle`ior cause or Tay D`e. amended of mod�Ued when considereC nec nary, tha.Co loner of H Itn, A change or elterstion '.of construction
... _.� _ ..:.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
10 COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION-TO C5 NSTRUCT- A4WATER" WELL
-)
PCHD PERMIT # _'� �(5
WELL LOCATION
Street Address
Town/Village/City Tax Grid Number
WELL OWNER
Name Mailing Address �� vX �i7d [private
/i�/a/�/��,� /f ICrHTl p � a M�ii/T C, LTA C/� /`7,EG /V y -O Public
USE OF- WELL
60- primary
2 - secondary
RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER. (specify,
O INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT
S gpm /# PEOPLE SERVED/ /EST. OF DAILY USAGE oy gal
REASON FOR
DRILLING
UREW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
N� G-r-
WELL TYPE
LODRILLED
ODRIVEN
"DUG ®GRAVEL ® OTHER
'IS WELL SITE SUBJECT TO FLOODING? YES L,-'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: S
Lot No.
41,
WATER WELL CONTRACTOR: Name Z V. Address: -
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: IVA TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF -THIS APPLICATION ' ON SE ARA SHE
Zz98
(&a-teY signature
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 s.hal.l :
1. Pump the well
2. Disinfect the
County Health
3. Submit a Well
Health Depart
Date of Issue:_
Date of Expiration:
until the water is clear.
well in accordance with the
Department attached to this
Completion Report on a form
anent.
-- 19
19
requirements
permit.
provided b,$
of the Putnam
Permit is Non - Transferrable ate COQ`
Yellow Dopy:
2/87 Pink Copy`
Orange copy:
H. D. File
Building Inspector
Owner
Well Driller
j�T t• �1' •JI t� �.
DIVISION .OF ENVnIONKRML HEMTH -SERVICES.
DISPOSAL
SYSTEM—_
_.
a-..,�:..;,�. .dDJE. SIGN :;DAT�k- ;SE3F�'�:�SIIk'A,�.:.:• x -- '
owner DE'r/,E��i�X� �j Cc:,aT12 Address jbooX 97o, C,4AA -1Z:z- A/ Y. /V_572
I41?M T_ itl;A1241_7
Located at (Street) JaC1ei /i✓4 701-' Sec. So Block z- . Lot ZG./
(indicate nearest cross streetY
Municipality' 7v wAl az- IP47, z�Os Watershed C fo Ta %V
SOIL PERCOLF CN -•TEST DATA RDQUIRED TO BE..SE&mn7ED WITH APPLICATIONS
Date of Pre- Soaking 7 2-9197 Date of Percolation Test 7 Zg b
'HOLE
NUMBER QA( C .TIME PEROQLATION Pm00LATION
Run Elapse ! Depth to Water �rcm water Level
No. Time I Ground Surface In Inches •Soil Rate ..
Start-Stop Min. Start Stop Drop In Min/In Drop.
C
Inches Inches � Inches
Y8 z
2 S- �'� "07 Z 27 3 0, z
;o s "6v
4 .. -.
.3 C9r63 s W, 11 Z Z 3 :o
4
5
2
3
4
NMS: 1. Tests to be repeated' at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to' be suhmitted;.
for review. r
2. Depth measurements to be made -fran top of hole.
rev. 9/85
s,
DEPTH HOLE -NO. d / HOLE NO. ppypO�-E NO
Y6W.iY 6W0
ca>.:.. wwy ...i_- �..u.....- ...`- .. -w.a�. y.iti ..n....¢..�.r,•x- ,i,..c uzr.z z.. ,.. e. - •:.'.. _ .. -
.. r_:... -.� .r..r- -v- :.
■�:e� /� rr .... ...... .. ... ...,rer.«r.....- r:.na+'r rt:..........w..a.- .ts r. •ry -..W. s:. F+. -.:. >_.:_< _'.. ...
VODO �d/�SvI
1°
2 ° S 9 /VIP
3° Ga%
6°
8°
9°
12 .
13°
141
INDICATE %EVEti A WHIQi GFtOUNU?_Vi ft IS. ENOOtINTERED /��%.
r
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTEEtID /1/1�,
DEEP HOLE OBSERVATIONS MADE BY DATE:
DESIGN
Soil Rate Used 6-8 Min/1'° Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity /Z SO gals. Tripe c �i ✓c:
Absorption Area Provided By 6/yL> L.P. ,x 24°0 width trend
Other
ell I-
Name Gib Am N /VGI��� ���'Y
/ZF.E2 %�jSc:K; ,:.0 C Signature
Address SEAL " ;1 r L L C LUI
• /� TT. � Sow /c�! �/ _ %�L �G 3 � ��� 1�;
eF ® No.
THIS SPACE FOR USE BY MALTH DEPART. ONLY: °��FESSla'
Soil Rate Approved sgoft%galp Checked by Date
O
Putnam County Department of Health
Division of Environmental Sanitation
AFFIDAVIT..-.--CORPORATE,-.OWNEPZ APPLICATION_
FOR PERMIT•APPLICATION SUBMITTED TO
PUTNAM COUNTY.11EALTH DEPARTMENT
TO: Commissioner'of Health In the matter of application for
06 >
n 6
6 7b
1 Lie Q L0 L <_ - - - - - -- --- - -_ + represent
that I am an officer or employee of the corporation and am authorlzed,-.,
to act for
(name, of carporari n)
having offices at tYtt 32
officers are
4J-�- _ Whose
President
Vice - President 6t0CC,9Lj"-7j G nl) czC_
Secretary
GJy- -_2 ee--
(Name and Address)
Treasurer
— — — — — — — — — — Address) — — — — — --- — — — — — — — —
(N�me- and
and that I am and will be individually responsible for any or all, acts
• of the 'corporation with -res'pect to the approval requested and all. 6ub-
sequeht acts rel* a 9 tin' . tliereto.'
Sworn to before me this _day Signed
7
of 198/ Title
'Rotary Public
ANNE B. COWDAN
k4r4mcaunty
Ir
• 0��
My
FR"441"d
� e C16�
peu
QU
Corporate Seal
U22-Dik"11 0-14U.
PUTNAM COUNTY DEPAKTMENr OF HEALTH - DIVISION OF ENVIRONMWAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
( o Owner)
REVIEW SHEET = CONSTRUCTIONT PEI2MZT:: p i n a. - - -
DA
BY
(Street Location)
DOCUMEM
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
Milo
s/s
SUBDIVISION
Perc _
(3) Fill
cd --
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Putmp.pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes. (grinder rater---- -
Des gn Liata: perc and deep results
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area; shoran; gravity flow, suf f . size
If Pwped Pit & D Box Shown & Detailed
House - No. of Bedroams
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 pine
No Bends; Max. Bends 45° w /cleanout
SEPARATION 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. expan)
15' to Drains - Curtain, Leader, Footing
35'to catch basin, stonndrain,piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' fran Foundation; 50' to well
15' Well to PL 9
Ii
920 POSED �
1Y,t/ I I
I,
I I
I
1'
J \
- \ \\ \\
\J
PRSPO 5 D
�
PROPOSED
P WISHED
GRADE
2 o Z
a
t N o
D O
n � h
Z Z Z
elLElj
'vr
=r
Y � '
- - - -- (54.
(54c)
PLAN
1" = 30'