HomeMy WebLinkAbout2054DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.48 -1 -30
BOX 18
o
I We
02054
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION 'rd - &6N51'RUC:'T' A WATER WELL �J
PCHD PERMIT #�1
WELL LOCATION
Street 4ddress Town T,V}}'llage City Tax
V E .,
Grid Number
WELL OWNER
Name
C- e, ki ri 4 iti
Mailing Address
n s7d n,
W(Private
O Public
USE OF WELL
1 - primary
2 - secondary
1 RESIDENTIAL
10 BUSINESS
O INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
C3INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE 00 gal
REASON FOR
.DRILLING
0 NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
JJREPLAtE EXISTING SUPPLY O DEEPEN EXISTING WELL .
® TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
FT
n U
WELL TYPE
®DRILLED
ODRIVEN
ODUG
GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES Y NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
[54 a5v
WATER WELL CONTRACTOR: NameRV&S DeC- dAZ,;t, (PCI1 En Address : � 0 � Qq 14tdm (gyp L� ' y
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES V NO
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
DISTANCE U 'PKOPEKTY TRUM WEAKEST' WAIER'MAIN c
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION O ON SEPARPMF ;ft-
(6at46 (signatu
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 provided by the Putnam County
Health Department.
Date of Issue: 19
Permit ssuin ffici
Date of Expiration:,A,1-7t v / 19___..
Permit is Non-Transferrable able Mite copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
i • ..�
. '
���� rt°
PVINAM COiJNTY DEPABTIYIENT DB HEALTH 3
Dh iWim d Eevkameentif a" Servk%ee: Caimel 14M. 10512 .�
C to PiovWe, Pesmlt N i i
TEOF!
CONSTQIIC110N PERMf! FOR SEWAfi6 ;DISPOSAL SYSTEM Perms N h ,,.'�,0'bE� .. �.
.E�/17�E YEGL.
own
Lets>t�a �t� -
n+ ....:.... ..,,.�,. .wS..a _. -- f- �..:.. �+c »• :...; �. y. �,:._ ,. ..- :...p. > �r- . rr.a •s.- .- .cn.a. .... - n.-v
S�bdlVWon Nsims /9� . of A 7 Lif ~cer,.t.`Lot p1P/ /9 - -/: Tw
�
lnerr � Na* ' oN
o i m d /er • Reneral' ❑ Revltilon ❑
..
Hate of Prevk►ne APprovW
Moul ig Ate, y Town
BO" T'Pe ®a GC %Cie%}»iE Lot Mai' >,� BOO t� 7` FQI Sectlon _ OW LJ Deptib yolame
Namtier of Bedeoome Design Flow. G P : D O PCHD NoH9txtlon le Bogblred whon Flll V 000tpleted
S"Mme Sews d S to oasseblt o[ /��� GaSon Took oo�
7N
To• a aemtiiacted by= 1('�L— _Li�IJ.D tp'� Address �S O �J ��2 S '
water,
orr ply Dewed by''
Of6ei. RON in manta x c
(,represent that 1 am wholly antl ctlmpletely responsible for the design` end location of the proposed systom(s) 1►; that the separate., sewage ,disposal system
above :described, will ba constructed as snows on the'approved ^amandme, ,the!a to and in, ccordance virith.the starid rds, rules_an regulations o e Putnam
County Oepsitrn"r' of•; MeeRh •'and that'on completion thsroof a Certificate , of Construction Compliance satisfactory ao, the'Commissloner of Healthwill .
be submitted, to t"- Department, and a written =:guarantee will be'lurnisAed tne' owner; his wcce to►i, nabs or essiggi.by the Ouildir, that said builds► will
place in good •operating: eonditlon any spirt of :: lid sewsge disposal system during the period of 'two (2) yars•immedlately . follow 14 thedate of the issu•
anceof tM approval of the Cerbfl ate of Construction `Compilince of the original system' or any repairs thereto; 2) that, the drilled well described above
will be loated'as shown,.ain the epprored plan and flat Y W well wi110e, install n secoralente with the • standards; rub's and ispu ani of the Putnam
COUnty Departure t of Malth Dr p y �
Oats fLO��f 0 Sgnad ri�� <,�. P.E. .. R.A.
Adtlrsss EL. ✓i�l/ Q . '% 4K 6`eien. No �II
. APPROVED FOR CONSTRUCTION This +approval „expnet -.two yan,`�from the Aate issued .unless const►ueti of the building has;been undertaken and is
ievocable (or cause or:may be amended or�modif�ed. when considered necessar ',tiy the`Commisfionsr of 4Mealthi Any change or alte►ation.of construction
►epuiros a new permit. `,' Approvsdjfor Disposal oTdomestic; sanitary 'fewi9 and /or W vat! water i only:
1/87
0
Z t.
1 ` • O
lolo
Olt
Ot
\ 111 at
In
\ \
\
-'111 .,,
', II \ \ \\ \ \\ \, t 111 _ a \ 1 \ \ }• "\ � (�C1 � •v I ' I
III 111 i I \\ ^• \� ^, i I � 1 \\�\.. \ � \`t` / ,�0 ��,. •`
I /1 K \\ � 1• -\ I �N
IN / i S `•«____. -- N i cps, 3
-_ - - - - -t
.I.
-----
III
Jla
r • , s , ti
��' � ----- /! l 4 ►' / it -QA
l /
•
it
of
a '. .`TEST: PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENC`.OUNMM IN TEST HOLES
DEPTH SOLE NO.'. HOLE NO. HOLE NO.
c-
1'
2' GOB
3'
4' // =
5'
6' (�
70
8'
g' iiU6TE So/Y/�_ �OC�G -T`s
10' O�
11'
12' /(/oTE /� OG �s F / 41- ,gam UQ �.✓/ 3 D/c
13' cd.Q rga2 �4FT�2 S� a2�7 v Oct /,
141 .. G�2 �.¢�iv ��.�.� �s /� �� cam✓
- INDICATE _Y-�L - - A�=-WHIC i--GROUNEWAM. - IS-EN00 NTERED
U _. _
INDICATE LEVEL TO'WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE: a/
DESIGN
Soil Rate Min/1" Drop: S.D. Usable Area Provid
No. of Bedrooms is Tank Capaci i gals. Type
Absorption Area Provided By F. x trench
Other
Name &d rTA�Ehl /l /o v1 .EZ-40. Ze, Signature
•
Address SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMW ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
w..:.'_..w_.n, .r... -./,= h:. ., --� .cx /� . ;. /„ ��•�_•,- .. ,r, i- k -.,.. :w•� �wef'...�. {:a-r. �_ ✓:v:x. r`_-�_ _ - .s.s� _ __.� K,.. e._..
IN
ov
.— _ I I I / /ice C1
to
c LA
so
m` I
\ O \
04
cn
Is 40
Is
_ _ \ / p'• I
1 .1 I / / � l • • I� 110. /
I I I --- --,s-- - —• \ I I
set
I------ - - - -;,. 4 ; ' t I,I 1 r.,, ; ' I '•.. \ \/
'
+ 1 I l 1 R -- ---- - -- - --
rrr -- _1
' 1 B I 1 ,,.• �r � i n �� I � I raref
--
b fit
Of
IN, top
' I � � � � l• t \ �. \S + t ` / / � �� rrr ' .arr .
Or
r .// 1 1 I = •err —� �/ in J 2Z \ \ \
. I " \,
ae• , •
fit
Ilk
4 \ ra _ \ ` I 0 0
too
is
1 ` I
. e\
r
tt
to
Of
- - - --
- -- ►/ + /d'/
cl
jo
of 14
r + / a it 11 l '; l '� • / / �h)�°
II.
'i
1V.
V.
In VI.
APPENDIX C
FINAL SITE INSPDCPION
TH $ OR . SUBDIVISION L(7P t
Date
Inspected by
Yrs
tivAGE DISPOSAL AREA
a. SDS area located as per approved plans
b. Fill section - Date of placement
2:1 barrier. LGTH WIDTH AVG.DPTH
c. Natural soil not stripped
d. Stone, brush, etc., greater than 15' from SDS area.
e. 100 ft. fran water course /wetlands.
SEw-AGE DISPOSAL SYS
a. Septic tank size - 1, 0 1,250
b. Septic tank ins eve1
c. 10' minim um frcm foundation
d. No 90° bends, cleancut within 10 ft. of 450 bend
®.
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tes`��
®•�
2. Protected below frost
3. Minimum 2 ft. original soil between box and tr es
f. JUNCTION BOX - properly set
g. TRENCHES
1. Length required - Z Lenath installed
2. Distance to watercourse measured: ft.
3. Installed according to 21an • V ..s.
4. Distance center to center
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet fran property line - 20 feet - foundations
7. Depth of trench < 30 'nches from surface
8. Rocco allowed for-Mrransion, 50%
9. Size of gravel 3/4 - If" d
10. Depth of gravel in tr 1 2'1 iimum
11. Pite ends capped
hq .P_ bT Olt DOSE SYSTEMS!
1. Size of punp chamber r .
-
2. Overflow tank X
�-
3. Alarm, visual /audio
4. Pump easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health Departnent
estimated flaw per cycle
HOUSE
a. House located per a , roved 1 s. �✓
b. Number of bedroans
I-
WELL
a. Well located as per a 22roved plans
b. Distance from SDS area measured ft. .....
c. Casing 18" above qrade.
d. Surface drainage around well acceptable.
OVERALL WORRMASHIP
a. Boxes properly grouted
b. All pipes partiallybackfilled
c. All 2ipes flush with inside of box
d. Backfill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
f. Curtain drain outfall p rotected & dir.to exist.watercours
g. Footing drains discharge away from SDS area
h. Surface water protection adequate
i. Errosion control provided on slopes greater than 15 %.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.. _, ... ...,.... _ � -Date
Re: Property of
Located at
(T) j rLc�2sa,� Section Block Lot
Subdivision of �ir'
Subdv. Lot Filed Map #_____, � Date
Gentlemen:
This letter is to authorize X.4T,TZ1Z -- t/
a duly licensed professional engiinye.eerr -! v or
(Indicate
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
ys �em-or' sys"tem's- -,rn�-confoPmity with the provis -ions or" brticle "t47 or"
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
Signed
Countersigned:
i°C Owner of Property.
� cc Qoa,,�
P.E. , Rt-�t: , #� 0611�.5 1% Address -
A d
a�,�9TTi�;�G
ress
Telephone
191�
6ree-✓s
Town
2-7 y-9'607
Telephone
PUTNAM CDUNT'Y DEPARTMENT OF HEALTH.. 4
DIVISION�OF HEALTH SERVICES
j" '
- -- - -. - DESIGN • DATP SHEET- SUBSUFA.CE -S90M DISPOSAL-SYSTEM
- -FILE N0.
Owner , ^— /Tf/o� if'1�P B <�" Address ,g P�6w
Located at (Street) Sec. Block Lot
(indicate nearest cross street)
Municipality ��TT� �S o Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMI= WITH APPLICATIONS
Date of Pre - Soaking d'Z_. Date of Percolation Test a
HOLE
NUMBER
CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water Fran
Water Level
No.
Time
Ground Surface
In Inches
Soil Rate
Start'- -Stop. Min.
Start Stop
Drop In
Min/In Drop
Inches Inches
Inches
m 1
/•'�? 8 - ®?.0 3
35�, a?/ �� 02.3 /.� ~
�? z ��
J/
�Timrsi�,r -�
2
.a ; - .a .',3
,mode o?J "
3
13oi+ o?l e?c3
A;Z
�.�ie►us�� -yi
4
5
3. _ .?/ .. ,?3 ,I R " jG.Jr.,vu��,s.�_
�- 2 '�3.•ii - i�• 03 saw;' d /'� �� 4 _ .. _ d _ 3 _ _
3 �.•or -- .0e: fes 38'x', a /'` 0?3 m2 " �y►,�,�'
5
�1 � • �S - ,,�: a?7 ,.�f.Z �� aJ' �� X1.3 " � � - l�f,f,� •
2 ,..� •a 8 - �f.� 07 - � X39 �/ ,r
4
5
NOTES: 1. Tests to. be repeated at same depth until apprcximately, equal soil rates
are obtained at each percolation test hole. All data to"be subiai.tted
for review.
2. Depth measurements to be made fran top of bole.
rev. 9/85
TEST PIT DATA REQUIRED. TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOIIS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. / HOLE NO. HOLE
NO. 3
G.L.... .m Ole .o�Gff/r/ /,e:�.:r. -....
_T Z?�,s'0/Z-
%oe"Sa iL .
2'
31 �r it
rl
4'
5' i r rr
r
6' Ir
�I
7' ,r
8' rr
If
91. CAM 72 .- Sd � �v ��� T d�
&-Z,11y
�i✓e.�z1wT� ���
10 r.
12' {
13' .
14�. _
INDICATE LEVF�` AT WATCH' GR()[7NDWAT IS ENUUUN7'r`Rm,
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
7/
DEEP HOLE OBSERVATIONS MADE BY: Q. 0 DATE: a/ 8
DESIGN
Soil Rate Used �_ Min /1" Drop: S.D. Usable Area Provided �O Q(
No. of Bedrooms 13 Septic Tank Capacity 06 o gals. Type CoI/C .
Absorption Area Provided By L.F. x,24" width trench
.�i�m
Name /ty p(/od.E-�,Lo� ��:,/?L6ignature
Address divs SEAL
T)HIS. SPACE FOR USE BY HEALTH DEPARTMEW ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date