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HomeMy WebLinkAbout1737DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -75 BOX 16 -2 I� . L �T 7 L. ; !'}61 ., _� r is ML r I �I 01737 ✓, Division of Etisvleoameatal Health Services Carmel N Y 10517 Eagtaeer to Provide Permit iY, , ioaCERTIFICATEOF MPLL�CE`r Permk 11; CONS CTION PERMIT FOR SEWAGE DISPOSAL SYSTEM } { .sP 9MY -'Y,.. � alW lil�r JVw. O�iF c:b:6, 1++.: � S Z•v m-- >c�'�me.,TSw. Locicea sc 01d Route 22 r : Tewn or vmager _ r,6 s i Sabdlvleloa Name �p�11 Hill Sabel Lot IY 7 Ta: Map 69 Btock rx 1 Renewil ❑ 4e. vision ❑ Owaer /AppRcaatName -Loft COr >p,Pump HOUSe -Brewster,NY if Date of Provloas Approval ' Aaare.. Pump House Road , Brewster, NY Towa Zjp P o- x t r Btwdwg lyk S - fig, le familw residQ&c 79, 007 sq .ft FW Secaen Daly Depth Volame Number of Bedrooms 3 bdrm Desl Flow G P M­600­ PCHD NotlBcatloa le Regalrod Wbea FIR Is completed Sop° `t Sowovrage system to consatof 1000 GaRoa Septic Taalc end 43Q lin ft di sposala trench 4 t ti tru ,f To be cnc —13y d��G AaaroserIaP�' H, 11 'R�arl i RrPW4tPr �X $ P k z Water`SaPPb Pdbllc Supply From Address 4 r or :__Prlvate+SapplyDrRledb B NYC Other :Renalrementa -' � : a _ ?. I repiesent that'1 sm wYY011y sntl- ..completely responsible for the d�esignsnd IocaGOn of the proposed syriam(s) 1) that the separate:sewag .r f7& above'tlekribeA wJl be constructed as shown on the approved; amendm'e'nt there to and �ri;scco dpnce with ttSb standards -,ih,i n regu a io County Department of` >`Hesfth, °and thaf on completion thereof a ,Ceitifi atii of Construction Compliance satisfactory to-the COTm F�sll r YO Ds sutrmdtetl` to the Department; and a w'tten,•guarantee`,will be furnished the owner',' his f4ccessors heirsor assigns by:the builds ha b' ilder- y pwce `'m gootl- oper't,�g contlitioh any ?part of said ewage tlisposaf system tlu►ing the perwd of two (2) years Immedutely follow' �'1Qte of issu= 'a, .K ance Of the .approvalof the Certd1cate of Construction Coinphance of theme ongfnsl System or any rapafrs thereto '.2) that fhs dr.fll' ; II`:ae`_ be will,be located,as snowwgi the approved plan and th$txsa �d well will be install in ccordaneea with the standards rules and regu a poi a County Department of rFiealth w Dam - 4 21 -88 F ) �17 Riper S'tr�eet arwick NY 1'0990 6' C� Adtlress + + License Nod„ ' APPROVEOtFOR CONSTRUCTION Th!s approval,exp�res two years,.,,trom the pate �sfued unless,eonstructiOn of -t -ne budding hastbee �eli���lf�is y" revocable for cause or Ti be! amended or modified when consideretl' cessar y y th ommissioner of Beal Any change or alteatfo requves a w par mit A ro for disDOSaI of ilomeriic "sanfta w end to a p my s 1/87 "", Date :. i i --'-�- -•+- i -^—^! ] "4 �k a' F �} h .. . k "-Tam; vsoPn DoTNAnvM r oCnOUeNnTaY DEARTaMN, HEALH Meath Re ces Ca rmel; h 6 L N Y 10512 z Enyeer'YItPmvlde'� -� - "� 4.... CEItTLFICATE F-CONSTRUCTIONsCOWLUNCE FOR SEWAGE.DISPOSAL:SYSTEM: '' tt ? Town oe Village "Located at i)S.QPL.Iv . -H I t-L izO.e.p" Taz Map Block Owner /applicant Name KtawJ Nl lcl- FA�� -5 dy Ion N e •bPPt.B { -'IISa t H 7 a, Forme am . Lo Sabdivle bdv Ro.eD Zip rogoq Mailing Address ,_ r r edr Date P.ermlt Isaa a - - /at.�er.a f&4Vr1a Bei�c 137 P.aTTe3RSOwJ N`r Separate Sewerage Syetembailt by Address _ r ''Conslstlii of COp'� Gallon`Septic'Tankand X30 L A1iSSORt°iTloral �R.:I.IC� -1 s. Water Supply )?a bOc Sapply Dona ' Address or ( r` Private 'Supply' Dsflled by M1uJ �It11.L��16y 'r�►G. Address `�L^ri�isH .a1lE �aa vJiS1ER.. ts'f Bollding,Type RES'1 t�ElJC� t Has Erosion Control 13e®n Completed? YES ,Nnmber'of Ifedrooms t 3 x Has `Garbage Grinder Seem Installed? Otber Regairemeate zsTl218LtTl t7n� 8oY S certifyxthat`thi system'('s) as aYsted serving the above piemises were constructed essentially as shoih.diithe plans of the completed work ( copies of which arenatiached)k ,and in accordancewith the ­- standards iule "E and xr i4ulatione '.in accordance ,with filed' plan, and the .permit issued by the •Putnam .County Dep�afrlt�mern -t Of 1Nealth ° - Date Ceied E. rtif � R.A. P r, Address " I1J'5� PG Ji2T 52 GRt�f6L,_WY Lleenss NO Zloo . Any person occuDYinq Premser ises ved by he t 1 bove9system(s) shstl,p►omptly taIt ' such,action ss,msy tro neattery to secure the correction of any unsanitary conditions r,gsultinq from " "such ;usage Approval of the separate' sewerage system shell become nuil'and 'void t'toon ii a pub;'_ sanitary lower becomes wgvaiiabie and thslapp ► oval of the.:pNvste water suDPly, hall;tiecome null and .void when a pupl{c watat- wpply - :O. eomss_avail�pN. - ,Such approvals are sub)ect ,two /modifiaatfon of change' when Jn the )udgmenYof the Commissioner of Health, such revoeattbn;' modification o► change It nieeaa►y./, D "' �(� ate ��- °'--�-- ���Titb -� %� ". �— ♦A��Ir. ._ -rAfT T111TAT1T WL'LL %jUr1rLz11VLV nr,KVltl � >, DEPARTMENT OF HEALTH __Divislon --Of-. Environmental. Health Services PUTNAM~ COUNTY DEPARTMENT• OF HEALTH Office Use Only WELL LOCATION 'STREET ADDRESS; 70NIVILLAUICHY TAX GRIOIVU BE 7., Apple Hill Road Brewster, New York �p'.L�. Lot 7 WELL OWNER NAME: ADDRESS: Ren Michaels 7 Apple Hill Rd., Brewster, NY P(PBIVATE 0 PUBLIC USE OF -WELL 1- primary 2 -- 'secondary SMESIDENTIAL 0 PUBLIC SUPPLY O AIR /COND. /HEAT PUMP ❑ ABANDONED 0 BUSINESS ❑ FARM .0 TEST /OBSERVATION O OTHER (specify) p INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm. /N0. PEOPL'E SERVED 3 to 5 EST. OF DAILY USAGE 400 gal. REASON FOR DRILLING MEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 405 ' ft. STATIC WATER LEVEL 3 0 ft. DATE MEASURED 10/10/88_ DRILLING EQUIPMENT O ROTARY -49 COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH 42 ft. MATERIALS: XX STEEL ❑ PLASTIC ❑ OTHER CASING DETAILS LENGTH.BELOW GRADE 41 ft. JOINTS: O WELDED XX THREADED ❑ OTHER DIAMETER 6 in. SEALK® CEMENT GROUT ❑ BENTONITE ❑OTHER WEIGHT PER FOOT 19 lb./ft. DRIVE SHOEMRYES D NO LINER:'❑ YES ❑ NO SCREEN DETAILS _FIRST DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? _.. _ _ _ _0 YES ONO HOURS StCGND _. _......... Y. . GRAVEL PACK ❑ YES O NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH _ft. BOTTOM .DEPTH ft. WELL YIELD TEST It detailed pumping METHOD: O PUMPED tests were done is in- � fat COMPRESSED AIR r formation attached? O BAILED ❑ OTHER i ❑ YES ❑ NO LOG It more detailed formation descriptions or sieve analyses are available, please attach. DE fAOM URFACE Water. Dear- Welt Dia- �eter FORMATION DESCRIPTION CODE. ' -ft . ling WELL DEPTH It. DURATION hr. min. ORAWOOWN It, YIELD gpm_ Lana Surface 18 405 Medium to hard grey & black crar 300 1 30 300 3 405 350 6 WATER X$CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? X® YES ❑ NO ANALYSIS ATTACHED ?M YES ❑ NO STORAGE TANK : ' TYP E Diaphragm CAPACITY 86 GAL. 23 WELL DRILLER NAME ADDRESS PutnamIAveDRILLfUC 4/88 Brewster, NY r Pres ident PUMP IMFORMATION TYPE submersible CAPACITY 10 Goulds 300 MAILER DEPTH 10EJ10412 230 1 MODEL VOLTAGE HP Lte. i PUTNAM COADN DEPARTMEW OF HEALTH 0IVIS10N OF FNVIROi0-- ifMAL;jlF.T .0 _..._ . Owner or Purchaser of Building Building Constructed by ,4f'Pl�M V41 t_ L_ QoAJC.t Location - Street . �.o-�i�so ►.I Municipality Building Type Section Block Lot j r r Subdivision Name Subdivision Lot # GUARANIEE 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 pro'ty, an r_ d that it has bee constructers. 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- or` a` period of two - years' immediately fbllowi -n`g` the "date -or- 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 determination 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 ,2 7. 19_ Signature 5E��r Title. General Contractor (Owner) - Signature Corporation Name (if Corp.) I l / ray. . 9/81; Corporation Name (if Corp.) ess �uR L,�gy BREWSTER LABORATORIES fioz "224 - BREV0tttR, N.Y...._._._ . 's (914) 225 -2072 - WATER ANALYSIS REPORT SAMPLE NO. 7106 SOURCE: Ken Michaels new well Apple Hill Development Brewster, New York COLLECTED: October 10 1988 BY: Mill 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. c • I r October 12 '1988 0 per 100 ml. JA Roy Bi twit P.E. - 1 ector Box 224 - BREWSTER, N.Y. (914) 225 -2072 - WATER ANALYSIS REPORT - SAMPLE NO. 7106 SOURCE: Ken Michaels new well Apple. Hill Development Brewster,. New York COLLECTED: October 10 1988 BY: Mill Drilling, Inc. BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method. 0 per 100 ml. This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. October 12 1988 �1 G,A'-�__ Roy Bi it P.E. D ector PUTNAM COUNTY HEALTH DEPAIU]MEbTr DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. / Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of L �/ 1+� INSPDCTION NAME ( Orig. Routine ��•a� , / / MEN FA�/ MAILING ADDRESS -- P.O. Box Post Office Zip Code olpi * -,i PERSON IN CHARGE OR INTERVIEWED _ / fL I . , . I Name and Title DATE �� TYPE FACILITY T Orig. Canplain Orig. Request _ Canpliance Canplaint Camp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other �T TIME ARRIVED �r� TIME LEFT �� Explain FINDINGS _ 19 / WWNI PERSON IN CHARGE OR INTERVIEWED: I.acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: INDIVIDUAL I' Y91' 9UPPLY SUBSURFACE SENAGE DISPOSAL SYSYb •.?I .t INSPECTION ,� ;_�� INSP. (Name oft)wnp (street t&ation) INITIAL SITE INSPECTION y. NO CM-ENTS Wetlands on/or proximate to property .............. Property lines or corners found ................... Can estimate house-location ........................ Will driveway 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 .................... ........ L I A D.H. 1 Lot Depth to G. W. Depth to rock Soil Description 0 ft. 3 ft. 6 ft. 9 ft. ..7;% . ft' D.H. 2 Lot Depth to G.W. Depth to rock 0 ft. 3 ft. 6 ft. 9 ft. .. _ _ . 12 ft. D.H. — Deep Hole G.W.- Groundwater D.H. 3 Lot Depth to G. W. Depth to rock Soil Descrintior ft. ft. ft. ft. ft: DATE: ° FINAL SITE INSPECTION INSP.BY: YES NO CCMKaITS House SSDS located per approved plan ............. Length of trench measured Width of trench average Slope of tile line and trench acceptable......... Roan allowed for expansion trenches .............. AIR Over 100 ft. fran 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:) ...................... Number of bedrooms checks ........................ Stones, brush, stumps, rubble, etc., greater than 15-ft. from nearest trench ................ 15 ft. of.peripheral soil horizontally from trench ..... ............................... Boxes properly set.. ................. o ........... Could surface runoff from driveway, roads, O ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE .................. DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641. APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Old Route 22 Town/Village/City Tax Patterson NY Grid Number 69 WELL OWNER Name Loft Corporation Address Pump House.Road, Brewster, NY Private p public USE OF WELL 1 - primary 2 - secondary ®RESIDENTIAL ❑ BUSINESS 11 INDUSTRIAL []PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM O TEST. /OBSERVATION d INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify; O. AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED 5 /EST. OF DAILY USAGE 600 gal REASON FOR DRILLING MNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING New ci agl a family rgoi depc;a WELL TYPE LX DRILLED DRIVEN DDUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:Annle Hill Development Lot No. 7 WATER WELL CONTRACTOR: Name Henry Boyd Address:Route 52 Carmel, NY IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: N/A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAR IEST WATER MAIN: N/A LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED Q ON REAR OF THIS APPLICATION ON SEPARATE SHEET 4/21/88 (date) PERMIT (signature) 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 tKe Putnam County Health Department attached to this permit. 3.' Submit a Well Completion Report on a form provided by the Putnam ounty Health Deparment. Date of Issue: V 19 �/ 1 Date of Expiration: 19 t ssuing Official Permit is Non - Transferrable \ 1 "1110. I [Iley I APP -.NDIX B Ii4n PUTNA.M COUNTY DEMARMMT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WAMR SUPPLY & S'JSSURFACE SEY AGE DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION P—M:Z= U5-VT- L6Vo* (dame -of Cwner ) M DATE RESV ; —10 a` BY: (Street Location) DCC<T ONTS Permit Application Corporate Resolution Plans - Three se Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results P°- rc.3ole Depth House Plan Two sets Well penrnit; PfXS letter Variance Request �P.L Legal Subdivision Suixavi lion ADOroval Checked Ex -a: proval SSDS Adj. Lots C' lecked Wetland (Town/DEC Pe_:ni t R & D) Data On DDS Plans & Permit-- Sam REQUIRED DEYLA iS ON PLANS Swage System Plan - ( north arrcw ) Se -race System Hydraulic Profile - C avi=-v r cw p117ill Profile & Dimensions - Volume D or J Box; Trendz /Gallery; Piro pit de to is Septic Tank - Size, Derail Well Detail, Se =vice Line - ".if =over. Cons - 2act on- Notes- (grinder rate')" -`, --- Design' Data: perc and deep res,ilt= Two -Foot Contours Existing & Proocsed Driveway & Slopes Cut Footing/Giitta-_ , Curtain Drains (disC-_�-:arge CH ) Perc & Deep Holes Located Representative of primary and ex-- ansion Expansion Area; shown; gravity flow, size If Pummed Pit & D Box Shown & D--t=--;led House -No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed System=_ Prope -rty Metes & Bounds House Setback Necessary (Tight lot) House Seger - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 45° w /clsrout SEPP. =0N DISTANCES SPBCIFIED CN K_ MN LVI- 7. s/s Sur.D SION Pe--::- (3) Fill c" Fields 10' to P.L., Driveway, Large Trees,Top of fil 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stre rn, Watercourse, lake (inc. ex-,an 15' to Drains - certain, leader, Footing 351to catch basin, stormdrain,mipaH wate-rcou's 10' to Water Line (pits -20') 50'.inte mittent drainage course Septic Tanks 10' fran Foundation; 50' to u .1 fin 0 a� LF trench provided,A /�. •' - �� IMP i F=.L SYSTEMS . - MIME 'UMEM E -ME _� EIEME DCC<T ONTS Permit Application Corporate Resolution Plans - Three se Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results P°- rc.3ole Depth House Plan Two sets Well penrnit; PfXS letter Variance Request �P.L Legal Subdivision Suixavi lion ADOroval Checked Ex -a: proval SSDS Adj. Lots C' lecked Wetland (Town/DEC Pe_:ni t R & D) Data On DDS Plans & Permit-- Sam REQUIRED DEYLA iS ON PLANS Swage System Plan - ( north arrcw ) Se -race System Hydraulic Profile - C avi=-v r cw p117ill Profile & Dimensions - Volume D or J Box; Trendz /Gallery; Piro pit de to is Septic Tank - Size, Derail Well Detail, Se =vice Line - ".if =over. Cons - 2act on- Notes- (grinder rate')" -`, --- Design' Data: perc and deep res,ilt= Two -Foot Contours Existing & Proocsed Driveway & Slopes Cut Footing/Giitta-_ , Curtain Drains (disC-_�-:arge CH ) Perc & Deep Holes Located Representative of primary and ex-- ansion Expansion Area; shown; gravity flow, size If Pummed Pit & D Box Shown & D--t=--;led House -No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed System=_ Prope -rty Metes & Bounds House Setback Necessary (Tight lot) House Seger - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 45° w /clsrout SEPP. =0N DISTANCES SPBCIFIED CN K_ MN LVI- 7. s/s Sur.D SION Pe--::- (3) Fill c" Fields 10' to P.L., Driveway, Large Trees,Top of fil 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stre rn, Watercourse, lake (inc. ex-,an 15' to Drains - certain, leader, Footing 351to catch basin, stormdrain,mipaH wate-rcou's 10' to Water Line (pits -20') 50'.inte mittent drainage course Septic Tanks 10' fran Foundation; 50' to u .1 17 RIVER STREET WARWICK, NEW YORK 10990 JOHN LEHMAN, P.E., P.C. CONSULTING ENGINEER (914) 986-7737, ._ y FAX: (914) 9B6 -0245 Mr. John Karell Jr., P.E. Director Environmental Health Services 110 Old Route 6 Center Carmel, NY 10512 Re: Loft Corporation Lot 7 Dear Mr. Karrell: May 20, 1988 We have made changes based on..- review sheet of May 10, 1988. The system has been realigned parllel to the contours. A standpipe has been added for the curtain drain. If you have any further questions please contact us. Sincerely yours, 'P:.�.._a. JOHN LEHMAN, P.E., P.C. CONSULTING_ ENGINEER 17 RIVER STREET WARWICK, NEW YORK 10990 Mr. John Karell, Director Environmental Health Services 110 Old Route 6 Center Carmel, NY 10512 Re: Loft Corporation Lot #7 Applehill Patte.raon, NY Dear Mr. Karell: (914) 986 -7737 FAX: (914) 986 -0245 April 21, 1988 Development Enclosed please find a construction permit, certified check in the amount of $100, corporate resolution, letter of authorization, design data sheet, permission to drill a well, 3 copies of the plot plan and 2 copies of the house plan, for Lot 7 of the above referenced project. These are submitted to you in order to obtain a construction permit for sewage disposal system. Thank you for your attention to this matter. If there are any questions please feel free to contact me. Sincerely +you s, John Lehman, P.E. Z APPENDIX M PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONNff !'AL HEALTH SERVICES AFFIDAVIT- CORPORATE OWIER APPLICATION FOR PEFMIT APPLICATION SUBMITTED To PUTNAM COUNTY HEALTH DEpARTMFM TO: Commissioner of Health In the matter of application for: i 11 ;I--, 1 ! I represent.that I am an officer or m_a-9yee of the C6rpOraticn and am authorized to act for O)C-.T— Co 12 (Name of Corpor.kion) having offices at A-) A 0 kw Z f, L r Whose officers are: President: —jo Vice-President: g 00, .-ess) (Nam and address) Secretary: (Name and..,address). 71- Treasurer: (Name and address}----� and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Sworn to before me this day Signed: of 19V Title: r/,72 9 No Public EILEEN A. IEZZI Notefy Ptgblh-, State of Now York Qualified in Putnam Count Commission Expires F130 20 PUTPIAM COUl'UY DEPARTMENT OF IiP�I1uni DIVISION OF EWIRONMENTAL I-1h!!LTH SERVICES COUNTY OFFICE BUIIDTNG CARNET; :._ N. v,v.�.__ 10512 _. DESIGN D_kTA SiTRE-T- SEPARATE SENAGE DISPOSAL SYSTEM FI7.l; N0.— Owner , j - j\ c ywjA rQ %A Address o,� o U-74- Located 'at (Street Ondlca,e Puz%MG .Sec. c�9 Block c.,. Lot nearest cross r�ei; } — Municip�lity�� -� Watershed SOIL PERCOLATION VEST DATA REQUIRED TO BE'' SbBMITTFd) W-l"I'11 APPLICATIONS Bole P;urrber °7 CLOCK TIP•, ,, PERCOLATION PERCOI•ATION __._.._ ap., Tx P, o Er -- ter N-vef luo. TIME) Prom Ground Sur 'ace in Fiches Sol! Rte Start -Stop I•lin. Start Stop Drop in Min./in drop Inches Irichus Inches J3 1 ? i3--g—_4 zz_. 2 A 3 icy© _mac?_ _7- 412 - -2 - - -___ i 1 ,05 : S ao _ 2 5LD-aL7 ALael -30 2, 5 l 2 j Idotes : 1) Tests to be repeated at san: ; depth until a proximatelyy equn 1 so:i.1 rates are obtained at each percolation test hole. Ayl data to be submitted for review. 2) Depth measurements to be u-nde from top of hole. TDST PIT DATA REQUIRED TO BE' SUBMITTED tJ_T.TFI APPLICATION DESCRIPTTON OFD' SOTIZ NC01)N�I'ERI D IN TDST HOLM DEPTH HOLE NO. 'T HOLE N0: BOLE NO. :Mp f261 t.. . 12" CLAM LQ&VA 18" - 21E" ,011 �6n _ 42" 4 811 511 11 6011 66" 7211 7811 8 It B -Csi. INDICATE Lt, EL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WITMIT WATER LI;` M RISTS AFTER BEING ENCOUNTERED '1'rs`_r's MADE BY t .mss nc i _� _ -51 E- ► a4 __• _._.._ Date, 02 /� L = _�___-= UES10N Soil Rate Used 20 MLn./1 "Drop : S.D. Usable Area Provided, 5,� No. of P .drooms z Septic Tank Capacity I.o ®tom Gal Absoz��ti.on Area Provided fay L.F.x2�E" 0 I;ii.X4- . I;a:ne _ _�,_jNt I.T�a� — Si (;nature - rn • L Address S U� TtIIS SPACE FOR USE BY 11,IILTH DEPARTMENT ONLY: Soil Rare Approved_ Sq. Pt /Cal. 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' � i ��� , � II r / / �'i / ; �: , , �. /i !,: Il I •. I �� �- ' �1� ', \• __a P �,;��5'�at� ,,�c� -•;:•, � ( *,`� yx,�J'''' >;•y%:,lt�M�f � I;1'II ; -- /F 4 - _ - o ", .; ' .i. /BLOCK LOT 7 ; •y' --/ ��' / %/ REFERENCE: TOP01 LEGEND BOUNDAS I /,�. - i / ,- �;'. s: • • — .CATCH BASIN ``� .- �: .•1,� ';�/ //� • — .MANHOLE .EXISTING BUILDING .PROPOSED DWELLING r— ZONE R-40 � % !/ NOTE: SEE SHEET 5 OF 5 FOR SEPTIC,WELL & DRAINAGE FACILITY LOCATIONS