HomeMy WebLinkAbout1704DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
35. -4 -25
BOX 15
01704
1 �;
' No
,,I
IN
01704
Rev. 3186 ti
�\\PA
CERTIMCA
Located at If/
PUTNA1Yf COUNTY DEPARTMENT OF HEALTH
Divislond Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide
P.C.H.D. Permit
OF. CONSTRUCT
Owner/applicant Name
Mailing Address
COMPLIANCE FOR SEWAGE DISPOSAL SY!
0
go Town or Village 'z Lot
Tax Map
Subdivision Nam Lot # 0
Date Permit issued "t
- 1 -
Separate Sewerage System built by 101WIS 0 0 V&V CJ ' "" Address
_25
Consisting of —Galion Septic Tank and 66
Water Supply: Public Supply From Address
'E'/ L� Address
or:- Private Supply DrIlled by 11- 1- 7261 LIA
Building Type W9 'Completed?-
P61 27 Has Erosion Control Been
Number of Bedrooms Has Garbage Grinder Been Installed?
Other Requirements
I certify that th ' e syste-m(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 regulations, in accordance with the filed plan, and the permit issued by the
Putnam County Department Of Health.
Date Cert;f led by 2",:2! P.E. R.A.
Addre Z Wllnss. No.
Any person occupyino'premises, served by the above sYstem(s) shall promptly take such action as may be necessary to secure the correction of any uns2nitary'
conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a pubt,': unitary 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 Commissioner o"ealth, such revocat Ion, modification or change Is necessary.
Date
-1
BRUYSTER
Box 224 - BREWSTER, N.Y.
(914) 279 -4945
SAMPLE N0:712 7 NEW WELL
SOURCE: Steinbeck Estates Lot 30
Indian Hill Rd.
Patterson, N.Y.
COLLECTED:11 -1- 8 8
BYMill Drilling, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
11 -3 -88
Thoinas Meyer
Director
0 per 100 ml.
PUTNAM COUNTY DEPARTIKENr OF. HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
/Za
Owner or Purchaser of Building Section Block Lot
J''ci �,�c` c" fit: lC ; -! < <, T'�,!�.—) <'�-
Building Constructed by
r/VM To FAP-m 7"o /t *tC-i Qom Sagb 1-.e 5 11,4
Location - Street Subdivision Name
p/dT7'12�0 /' ��h� i./l)
Municipality. Subdivision Lot #
Building Type'
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 irmediately 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 "6y "tfie' will "ful or negligent act*-of--the - occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive
the Director of the Division of Environmental Health Services
Department of Health as to whether or not the failure of the
caused by the willful or negligent act of the occupant of the
the system.
Dated this 't6
day of Olj
19_ff Signature
fo Aly � I I
Address P /zxz
rev. 9/85
mk
ri
,/
Title
the determination of
of the Putnam County
system to operate was
building utilizing
Address
gym,L,ro
��� �,�
a,
t p
IWELLLOCATION'
Wr,LL l,Vl1rLJ,11V1V >cr.rvl<i Office Use Only
DEPARTMENT OF HEALTH
__,....__ ..... .D.. i...v.. teion -Of. Environmeuta.1 liealth Services
t. .... r.,. ... ' _
PUTNAM COUNTY DEPARTMENT OF HEALTH
STREET AOURESS: WN /vll / 1 Y TAX GRID NUMBER:
Steinbeck Estates, Farm -,to- Market Rd., Patterson,..NY mot 30'
WELL OWNER
NAME: Monroe Heights DevelopTtent CortWion,
PO Box 970, Carmel, New York 10512
MCPBIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
X3 RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED
O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm.' /N0. PEOPLE SERVED 3 to 5 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
10 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH .365 ft.
STATIC WATER LEVEL 30 ft.
DATE MEASURED 10/28/88
DRILLING
EQUIPMENT
O, ROTARY 36&COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. Jffl OPEN HOLE IN BEDROCK O OTHER.
CASING
DETAILS
TOTAL LENGTH S5 ft
MATERIALS: 1 STEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE 64 ft.
JOINTS: O WELDED NaTHREADED 0 OTHER
DIAMETER in.
SEAL:.fR CEMENT GROUT ❑BENTONITE ❑OTHER
WEIGHT
PER FOOT 19 Ib. /ft.
I DRIVE SHOE.4 YES O NO
LINER: O YES ONO
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
__ OETALL$
FIRST
_O -YES O NO
HOURS
SECOND
-. — -_
..�
GRAVEL PACK
11, YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL'YIELD TEST It detailed pumping
t
METHOD: O PUMPED 1 tests were done is in-
Xj COMP RESSED AIR , formation attached?
O BAILED O OTHER ; O YES O NO
/EL1. LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water Well
Sear- Dia-
ing (peter
FORMATION DESCRIPTION
CODE.
tt
ft
WELL DEPTH
ft.
DURATION
hr, min.
DRAWOOWN
ft.
YIELD
gFm.
Surnlace
50
.55
Soft weathered ledge.
300
1
30
300
1
to haFrd pink & e grans
.
365
6
-
300
8�2-
WATEfi JaCCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? AYES ONO
ANALYSIS ATTACHED? YES ONO
Ell
STORAGE TANK: TYPE Diaphragm
CAPACITY 82 GAL. 23
PUMP INFORMATION
TYPE submersible CAPACITY 10
Goulds 300
MAKER DEPTH
10FJ07412 230 3 4
MODEL VOLTAGE HP �
WELL DRILLER NAME MILL 0 T
Putnam-Ave.pRILLIlVG, /2/8 0
ADDRESS. SIG? t .
Brewster, NY
M
II.
IV.
V.
VIT-
FINAL SITEVINSPSCTION Date
Insre=-.tgi by
;•;C TIC?N CWNER r*�� °
a �? ° T A OR SJEDIMION LOT #
__..�
....I . YES.. NO
a_ SLS area located as per approved plans
b.
Fill section - Date of place-nent
2:1 barrier. 1= WIDTH AVG . DPIH
c.
Natural soL nct stri-ored
d_
Saone, brush, etc., enter than 15' fran SDS are=_
-
e.
100 ft_ fran water course /wetlands.
SE• =-E DISr'GSe?-r, SYSTEM
a. Sentic tank size - 1,000 1,250
I
b.
Septic tank installed level
c.
101 - nunirmin fran foundation
( I Al"
d_
Nc 90° bends, cieancut within 10 fz_ of 45° bend
r
I
e.
DISTRIBUTIGN EQX
1. ALl cutlets at same eleva ti on - water AWN-
(
I
2.- Protected below frest �
{
3. Mini= 2 ft. ericrina l soil b�bo and Wenches
( I
Q
f .
EOX - crct>e--1v se_
I }? I IV,
Le_ c lh installed
7 411 11
2: Di'sranee to vat`rccurse me= -ur= J f `.
.3. ins taL? ed ac--rd.-Ling to to n
4 Distance .: center to cent`r
.5.. Slcr.,=- of t_Ench- accent ble 1 /16 - 1/32 " /feet:
I {
6..10 -fe-t f ::= :.urc-certy line - 20 feet -,Ac-&d�ticnv I
7. Demt_z of t_encz < 30 inches fran
8. Rcan allcwe= fcr. . e ransicn, 50%
I 1
J Size of cave 3/4 - 1'" di��eter
10. Dent_n of aravel in trench 12" min?rmm►
L. Pirre ends cps
I
h.
P.2�ro OR DOSE SYSTEMS
1. Size ... of .....c��
2. Ove_rflcw tank
I I
3. Alan, visual /audio
I
4. Pu= easi1v accessible manhole to'crade,
5. First bcx_1e✓
( I }
6. Cycle wit�e_ssed by Health De argent
estimatea f! cw per cycle
HOG...:
a- Ecuse located re* amroved plans _
I I
b _
hi -ice of bearcans
{
WM
a.
i.
Well located; as per acnrovea plans
I I I
b.
Distance from SDS area measured ft_
c.
Csincr 18" abcve grade-
d-
S=.-Eace drainace around weU acceptable_
OVEP -A- • WC)RK ,4 -ASiff-m
a_ Er-Yes properly arcuted
I ( I
b.
A1? ires -r -,la? 1v backiilled
c_
k ipes flush with inside of box
I
d.
BEckf.ill material contains stones < 4" in diameter
I
e_
C:.--tain drain installed accordinc to plan
f.
C-,-,a.-:,n drain cutfall pratected & dir. to exist_watercours,
g..
Footing drain-- discharce away fran SIDS area
h-
S=---ace water Prot- --tien adecuate
i _
E.icn =ntrci provided en slopes are?ter than 15� .
I I
I
6o `.0t�0 jplrevlde Pee®lt_q,
Rev.
1/87
1 represent t
above, doscri
pbce'm goo0
'.of .the 'proposeG .system(s);_ l),, that
lndAr accordance with the'standards,
Construction- Compliance e satisfacto
owner his wceessors, •heirs or assign
ing ,the period. of two (2) years ImmI
I�nal fystem oi,any repak!�ther to; 2
accordance'with the standai rule
thwill
Ir Will
B issu-
above
COUnty Department Ot :Health =
Oat® o Sgned. P E R A. —
O:
Atldress License No so Z
-APPROVED FOR CONSTRUCTION Tnii approvalwezpires two yams, from.the"rdate 'issued unless construction of the building has been undertaken and is
revocable for cause PC may:,beiarnen"d — or mbdiikkl? when conside ` 'neee'_.ry,by t - .Commissioner of. eelt�., Any Change or..alteration of construction
re0uiies a 9 /w.D�er /mit., ADDpr00%m for disposal of:domest9c sa dar' age, an r,vate wa "r ly only. /
Date C eY .' Title `
m
d�
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APP1,iCAT1 ON' 'TO CONSTRUCT' A WATER Wtft -
PCHD PERMIT #
WELL LOCATION
Street Address Town Tax Grid Number
rYt Ta Ml�iz 7 12r1A'✓J -mKsotJ Ad 1?43 �b
WELL OWNER
Name
dWf- W PK14r
Mailing Address p e, �K �17a
D*V. Co, L a. GAerwr,4_ N d I2
AfPrivate
DPublic
USE OF WELL
�- primary
2 - secondary
ArRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP
D FARM O TEST /OBSERVATION
0 INSTITUTIONAL O STAND -BY.
0 ABANDONED
0 OTHER (specify,
O'
AMOUNT OF USE
YIELD SOUGHT
57, 9 gpm /# PEOPLE SERVED 4, /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
'MEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
13REPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
O TEST OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
gDRILLED
13DRIVEN
E]DUG
OGRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: NIt_.l.
Lot No. 3 o
WATER WELL CONTRACTOR: Name V%:7t,_jzmj&) W Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: ).J1�` TOWN /VIL /CITY
-DISTANCE "TO PROPERTY FROM NEAREST WATER MAIN: ..AA-_
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
r �$
[]ON REAR OF THIS APPLICATION SEPARATE SH T
(date) (si ature)
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.hall:
1. Pump the well
2. Disinfect the
County Health
3. Submit a Well
Health jarti
Date of Issue:
Date of Expiration:
until the water is clear.
well in accordance with the requirements of the Putnam
Department attached to this permit.
Completion Report on a form provide by t e P tnam County
vent.
�19
19 Per Issuing Official
Permit is Non - Transferrable
2/87
wnite copy:
Yellow copy:
Pink Copy:
Orange copy:
H. D. File
Building Inspector
Owner
Well Driller
• APPENDIX B
PUTNAM CCUNr'Y DEPARTMENT OF HEALTH. _ DIVISIM OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL MMR SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
4-0&
(z of CwneT)
REVTF,1 .S�_ r CCr1ST?=— �.
DATE Fj.,�V =:vc�:
BY: _J l L:: ---_-
(Street Lecrticn)
YES No DCCrTw_MS
CCi�Pr'S
I I
I
I
I
I
I
I
I
i
i
I
I I
I
Lc' era. ^_c:l provlC�
re ulred 3 3
60 f t. cr.: ,'.
Parallel t contours
100% e.�.
I
I
I
�c S S
t
FT?L S STEPS
clavL'a.rrier
- fill note
n --s
a� uges I
100 -. fl elev.
200 ft. r ervoir, etc.
RL
150 ft. igall /call.
I
P 't Art 1' t'
r.1 - 3 0
..ru
ion
Corporate Resolution
Plans - Three sets
Engineers A_ut.horizaticn
Design Data Sheet (DDS)
Deep Hole Lcg
Consistent Perc Res•,its
Pere Hole Depth
s/ /CZ
SUMM,
Perc
(3) Fill
cd ` "-
House Plans - Two sets .
Well Peru t; P'ls letter
Variance Re?uest
CE RAL
Leal Subdivision
Sabdilvision Approval C:nec c d
Ex- ac_•rcval SSDS Pte- Lots Checxcei
Wetland (Tcw -n /DEC Permit R & D)
Data Cn DDS Plans & Per-nit Same
REQTj= DETA TT S ON P??`S
S� age Svstem Plan - (aortn a=_cw)
StFwace SystaIl C1Vr'saul i c PrOL;! = - Gravity �V F_CIA
Fill Profile & Dimensions - Vo1=1a
D or J Box;Trendn /Gallery; P=imp pit details
Septic Tank - Size, De*-il
Well Detail, Service Line i- over
Construction Notes (grinder rat=_)
j�ccicTr� ilaf?" nerC•- ?lbdJd� °J ras!
"r
Zino -Foot Contours Existing & Proposed
Driveay & Slopes Cut
Footin /Gatter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area; shoran; gravity flow, ssfi .. size
If Pmued Pit & D Box Shown & Detailed
House -No. of Bedroans
Wells & SSDS's w /in .200 ft. of Proposed SystaT
Prope -ty Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; T_rce pipe
No Beads; Max. Bends 45° w/c e.nout
SEPa=0N DISTANCES SPECIFIED CN PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of f_
20' to Foundation walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Eke (inc. e_t-p`
15' to Drains - Curtain, Leader, Footing
35'to catch basin, storndrain,ciced waterccur
10' to Water Line (pits -201)
50' inte_nnittent drainage course
Septic Tanks .
10' fran Foundation; 50' to cell
15' Well to PL 9
a
Putnam County Department of ff alth
Division.of Environmental Sanitation:
AFFIDAVIT - CORPORATE. OWNER- APP_GLCATLON FOR PERMIT.APPLICATION SUBMITTED TO
PUTNAM COUNTY .}SALT+ DEPARTMENT
Tb: Commissioner.of Health -'In the matter of application for °
_, o�I�Qo E . n ifZS �EGo,PiYl
— — — — -- _
I .�—
Lie C�o�NT -� — — •- — _..= _....^ represent
that I am -an officer or employee of the corporation -and arn.authorlied
to act
(name of corporation)
having offices at y_qy _. L_
�— �OSl _ Whose- officers are
_ " —... _ _....:... .
President Y _Name a nd A TEk'
_
Zr7,,Sj-
-2)Ao V ice - President e- fi4 -7
(Name and Address)
Secretary l _ G Lo _ C.0 [- �-vt 7/ _ G _0111 _ iCl _
— — - (Name and Address) _
—.—
(Name. and Address) • ' — _ _ and that I am and will be individually responsible for any or all, acts
of the corporation with - respect to the approval r quested and all _ sub-
sequent acts relatin * thereto. ' -
Sworn to before me this Signed of 198 Title
otary Public
ANNE B..CObRIDAN
i ly conti„tsrrca"
Rol 04 u,,
Rea +�%���
Peo
W
0
y
Corporate, Seal
�ft+�
vv174Gnw rvR x I � ww+vn I -
'e. EINi9i1ED GRADE
4
i
A3- VUILT
V.IMGN910N'LMAK-
•N
A,
%
5
'19r5"
r,.Oj4.
G
10$-2•
to &' -T
q
R5 5
105•8"
10
:G0 ' '0'
iG2-0"
%8' P'
1! 0' .
0
/
r
/
/Gr70)
,. * TH1919�OGP .fZ7;fFY1'f- 1Ax'7H�:l�WAGe-
01�P0°,/At.:9Y9TEM WAS- .GON9TKiJGTe� A`7 - (y1G) �� /� i
INflIGATP!0 ON 7Y(1� PLAN AN(i_:TNAT CNL (�j1<1)'' •moo ��
'lY°�TPiM'WAtti ItJaJPCGrE4yPlY
• I'f.'YJAz,I;GOVP.iyL�'OdPi(L 7i•I[i9`f?f�M
GON�7F�UGT�D'fN: AG60MOANGe;l KfVITN /ql !
5`(ANf7AI�6? IZVI.t'h 0 K2E.{iUl•- AY1QkK30F�'fHfBi `(yG6) -
PUTNAM 6V?,I T t%K:PAf2Tf ��j f j QP HVAUTH, �
AND 1HE't1EW iOt2�`✓TA1t: t9ex 2TMeNT
aUO7P/. NOU %�. LOGA7�lON'- fAKt;N FIeOM •_CS— �.� - -� �� /_
O*L)f2VE`( OF PI- OPI:Kt f ° PtZEPAtLi;D FOf-- 1512
'/TiGHAeL N A LUKA 9. 1j)WNO; f'KL(Afe K?
JY G'ONTKAGTOIZy LfNE:
/ � h