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HomeMy WebLinkAbout2119DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 45. -4 -1.1 BOX 18 02119 I ' I f i .r L r AM 7fl;or - IN Or I�`� .� � T 0 lr k k I RR f T . r r k � ' r., i 02119 { k - PUTNAM COIINTY DEPARTMENT OF HEALTH 'Re V . '3/ 6 Division of Environmental Health Servlcex, Carmel, N Y 10512 ' r Engineer,, ,,, Pro vide -± P C. D Permit M f WELL COMYLETIUDI ruxuxi * * DEPARTMENT OF HEALTH " Division Of Env ironme ntal 'Health- "Se°rvices PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET AOURESS: WNW i TA% GRID NUMBER: ZIwg�R Rto, Brewster, New York WELL OWNER NAME: ADDRESS: Randolph Laurent, Zimmer Road, Brewster, New York BIVATE o PUBLIC USE`OF WELL 1 - primary 2 - secondary xgJcRESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY O MOUNT OF USE YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 3 / EST. OF DAILY USAGE gal. REASON FOR DRILLING .[]REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ®ADDITIONAL SUPPLY xgNEW SUPPLY (NEW DWELLING) ® DEEPEN EXISTING WELL DEPTH DATA 365 WELL DEPTH ft. 75 STATIC WATER LEVEL ft. 7112196 DATE MEASURED DRILLING EQUIPMENT O ROTARY x&COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT 0 CABLE PERCUSSION O OTHER (specify): WELL TYPE O SCREENED O OPEN END CASING x&cOPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH 35 fL MATERIALS: - 41STEEL O PLASTIC ❑ OTHER LENGTH BELOW GRADE ft. JOINTS: O WELDED xQcTHREADED ❑ OTHER DIAMETER 6 in. SEAL:QCEMENT GROUT ❑ BENTONITE ❑OTHER WEIGHT PER FOOT i9 Ib. /ft. I DRIVE SHOEQ YES ONO I LINER: DYES ONO SCREEN _ . _DETAILS DIAMETER (in) SLOT SIZE LENGTH (It) DEPTH TO SCREEN (It) DEVELOPED? FIRST O YES ONO SECOND - _ - - y GRAVEL PACK O YES O NO GRAVEL SIZE: DIAMETER -OF PACK in. TOP DEPTH ft. BOTTOAS DEPTH ft° WELL YIELD TEST If detailed pumping P P 9 METHOD: O PUMPED i tests were done is in- OMPRESSED AIR , ! ormation attached? O BAILED O OTHER ❑ YES O NO WELL LOG It more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFABear- ino Wei Dia' meter FORMATION DESCRIPTION ^ coat ti. WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gCm. Surface 6 1 Sandy loam & cobbles 6 365 & white granite, Hard e e 300 2 30 300 4 365 6 — 150 75. WATER xAWCLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? x:QcYES ONO ANALYSIS ATTACHED? DES O NO STORAGE TANK: TYPE tjanhMam CAPACITY 86 GAT,. 23 INFORMATION TYPE submersible CAPACITY 10 MAKER Goulds DEPTH 200 MODEL 1=— 104.1 VOLTAGE 22301P _L_ WELL DRILLER NAME MILL rnzuLl , / 25196 ADDRESS Putnam GN RE --� Ave. tive . Brewster, N(, Robert ,'bt. 1Ni 1 l Pr it J /bV PUMPM C OC N DEPATMaD7Z ` OF HEAMH DIVISION OF ENVIRO�LVrP.L fiEn1,TH SERVIQ S Owner or Puxcbaser of Building Building Constructed by Location — Street b%nicipality Building 1 .3 Section Block Lot Subdivision Nam✓ Sah.divis.ion Lot GO- i�RAI,7 LF OF SL�T_SU Fr.(ti Sa'tAGEE DISFCL�r, SXS r •i I represent that I am.. wholly. and co.�pletely responsible for the lccaticn, wor }a�ariship, material, construction and drainage of the sewage "disposal system serving the above described property, and. that it has -been constructed as sham on the aooroved -plaft or aoprov.ed amendment. thereto,:.. a-nd 'in accordance with the staneards, rules and regulations 'of: the .Putrani County D`parl riant of Health, and ,hereby gua.La:ter to the a ner, his successors, heirs or assigns, to place in goed operating condition any part of said system, constructed by me which fails to operate for a period of t _=, v.. two years iediately following the date of approval of the " ertificate of Construction Comno! lance" for the sewage cusposal system, or any repairs : ade by .r,y-- to such system, except where the failure to operate . properly is caused by the willfu'1 or negligent act or= the cccupant.of the building utilizing the ., The undersigned further agrees to zccept as conclusive the dete_mLIPa.tion or t)e Director of the Division of Fnviron:er.L -_J_ Health. Services of the Putnam County Derartr.ent o= Bealth as.. to w�,,etherr or not the failure of the system to o�aerate was caused by the willful or neglicent act o_ the occueant t= -. e building utilizing the system. Iktcd this . 1-991 , Sicna tur e of- Title C- r'ne.ra�_ Contractor (Cwnex) - Szgnatare Corroraticn (1% Cora. ) Corporation tie (ii- Corp.) eSS -- t� ' ess Mj ej S { j65 a� r e %r . O/O 5 i� l_ ..:: ,.. TARLTON ENVIRONMENTAL LABORATORY, INC. A Division of Northeast Laboratories, Inc.. _ - .. _ .__ . cT Cert: PH -0404 DANBURY: 39 -3 MILL PLAIN ROAD - DANBURY, CT 06811 and PH -0606 BERLIN: 129 MILL STREET - BERLIN, CT 06037 NY Cert: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: MILL DRILLING, INC. PUTNAM AVENUE BREWSTER, N.Y. 10509 DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: DATE(S) TESTED: TESTED BY: REPORT DATE: 11/19/96 9:30 A.M. RUSS 11/19/96 11/19/96 LAB #11471 11/21/96 SAMPLE SITE: LAURA.NT, ZBEVIER RD, PATTERSON, N.Y. SAMPLING POINT: BOTTOM OF TANK SOURCE: WELL -NEW TREATMENT: NONE TEST PERFORMED RESULT:.. RECOMMENDED LIMIT BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml CHEMISTRY: Chlorine Residual ND mg/L - - - -- m1= milliliter mg/L = milligrams per Liter ND = none detected RESULTS BASED ON SAMPLES SUBMTTTED:11 /19/96 SAMPLE, AS TESTED ABOVE: MOTABLE or F— POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) 0 Laboratory Director CT: DANBURYAREA (203) 748 -7903 - FAX (203) 748 -0652 - CT: NEWBRITAIN/HARTFORDAREA (860) 828 -9787 - FAX (860) 829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 - OUTSIDE CT: 800 - 654 -1230 I j TE O OOABIIANC� .jam" J� .. •- � �IiON PElbQP FOB SEWAM DWW" SYSTEM T- t¢`%%iPSOA/ Y LjtiMd �t - %A�LANY iii4LG: �� ar- vSlaae. af,rPna m ca49:'pot # /s �3cf Y - _ aeoe o.,ri t ❑ — R ❑ S Dae.or Prevoas Appoal MEN" 11AYALN T _ R�= Town & qum a --/ IA-0 wp Date Subdivision Approved Fee Enclosed ® Amnrmt • lot Area Fm s«t 0, DeP& vdbore Nubie of Hed<000a y Delon, F)ow G P D PCHD Nedecitim 4 Qeip i When AS )s d Sepa1131s Sewee Sq*c Tank S g� lat t D To 6e aednKted b� 7`t�17 Address Wetter Sttpp�/. PWWIC St4PI7 Ptm Addren Girt k Prkate Sim* Deed by 1 ripresent .'tries 1 am wholly ang eompMtaty r.ipons�ble for the tlssgn and'tocation . Of, the proposed system(s); 1) that the separate sewage disposiU s stem above described wilfge constructed as shown the approved irneritlrnent there to and in. accordance with the standards, rules a ►egu ens o nam County on rtinent of IIa1itQ and that on complatiOn themof i •'Certificate of Cor structlon Compliance" atisfactory to the .Commis now' of Meaithwill till s"Ol ted to. tM Department .arW;a writteh;quarantea'will pe,.furnisfib the owner; his successor; Mfrs or angns by'the pulkMr. that sif0 Oui1Mr will Otaee i11 goia operating 'it IN ahy'part� of aid wwaga:dispoal system duri p the period of two (2) yearsimmediately folbwing.thadateof` the ism- of n h orginil system W any NW INS thwet0:,2)'that the drillid well'deser*44 above wN a Ibtatetl -'s thawn' dot{ tM �pOr ed PNn aela N�ttai0 Compliance M instat in' accordance with the nilar WHO Olaf Oapattmint of. Mwftti. s, ubs 'antl r.yu ons of tM Putnam oat• ���. 9_s Sioneq_ . APPROVED FOR CONSTRUCTIDN..This approval expires two years if revocable for cause or -may Oe_ amerWlA;or;modifiad when confidired,na requires a permit. Approved - foa,ditposal of domistie sanitary Rev. 10/88 Date m ice se No i,the tlats issued unless construction of the building .Ms been undertaken and is ,sary.,by the Commissioner of Health. Any change or alteration of construction ., and only. . Tit DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 A_Y'PLICATION � TO � CONSTRUCT ' A WATER` WELL PCHD PERMIT # 1 �� WELL LOCATION Sweet Address /y7 own illage City 6 Tax Grid Number 3 - WELL OWNER ame Marling Address ADPrivate O Public USE OF WELL 0) - primary 2- secondary 19 RESIDENTIAL D BUSINESS D INDUSTRIAL D PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify, 0 INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT S gpm /# 0 REPLACE EXISTING SUPPLY ® NEW SUPPLY NEW DWELLING PEOPLE SERVED /EST. O TEST /OBSERVATION ® DEEPEN EXISTING WELL OF DAILY USAGE�'dy star L1 ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING < G WELL TYPE DRILLED DDRIVEN ®DUG OGRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: L' Lot No. WATER WELL CONTRACTOR: Name T,[34> Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __NO NAME OF PUBLIC WATER SUPPLY: A TOWN /VIL /CITY DISTANCE TO PROPERTY% FROM : NEAREST -: WATER: MAIN:_ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON SEPARATE SHEET (date) s 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 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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue : -z' 19 g� Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller _PUT'NAM. COUNM DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMIIML HEALTH SERVICES bESIGN' DATA :SHEET- SUBSUFAC-E-SEWAGE DISPOSAL ,SYSTEM .- ,r, X10, Owner /:'/VAT Z ,4:/�= A17 . Address /S Located at (Street) lf� Sec. 3y . Block _ Lot / (indicate nearest cross street) Municipality 7`TiC',`rCit/ Watershed. SOIL PERCOLATION TEST DATA•REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre - Soaking Date of Percolation Test L07- / HOLE NUMBER . CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water-Level No. Time Ground - Surface In Inches Soil Rate Start -Stop Mina -Start Stop Drop In _. Min /In Drop - Inches Inches Inches / - /O /S. ZZ L5e o 3„ 4 r NOTES: 1. Tests to be repeated at same depth . until -approximately ..equal. soil -rates are.obtained-at each percolation test hole. All data to be sukmitted for review. ' 2. Depth measurements to be made frcm top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. Z HOLE NO.* G.L. T 2' S� /��Sr: Mil s%�I� �eraw 5 6' Srn�,s 8' 9' 10' 11' . 12' 14' INDICATE LEVEL. AT .IfdICH;.GROUNDWATER IS - ENCOUNTER-W. INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY:', /i4��.re7� G'�! /<1'srci� ?i DATE: DESIGN Soil Rate Used -/U Min /1" Drop: S.D. Usable Area Provided No, of Bedrooms Septic Tank Capacity gals: Type �o�c Absorption Area Provided By l_ L.F. x 24" width' trench Other _ .. ► i �� C ►v c W, yo Name Af/ .cNT'�NGiiY�Er�/G �ssi- frF_r, Vic.. Signature N� l Address SEAL y C, No. 56124 THIS SPACE FOR USE BY HEALTH DEPARTMENT -ONLY: Rp�`ti;�t``./ Soil'Rate Approved sq. ft %gal. Checked by Date y. APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL.SYST'EH Name: and Address of Applicant: &!!VE :4 ,EwT /%giro rtTi y Lj� 2. Name of Project: ' 160 3. _•_Locationo/V /C: 4. Project Engineer: A,4'e 1x1 e&;,�x��s 5, Address: Nillbrooke Office Cent Brewster, NY 10-509 License Number:. V7-; Phone: (914) 278 76105 .6. T'Y� of Pro ect: Private /Residential Food.Service ....Corenercial , Apartments. Institutional Hobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject•to IState Environmental - Quality Review (SEQR) ? Type Status (Check One) Type I.. Exempt Type II. Unlisted. _ c 8. Is a Draft Environmental Impact Statement (DEIS) required? ............:.. 9., Has DEIS been completed and found acceptable by Lead Agency? . 10. Name of Lead Agency 1.1 -:.Is this project in an area under-'the control of •local­plannifig., zoning, orother officials, ordinances? .......................... 12. If so, have plans been .submitted to such : author. s ties ........... :.......... 13.-Has preliminary approval beep 'granted by such authorities? Date Granted: N /.� s . 14'. Type of Sewage Disposal: System Discharge...... -Surface Water'_ k_Ground Waters 15. If surface Hater discharge, what is the strean class designation ?........ :6 Waters index number (surface) —�- '�. Is project located near a public water supply system? .................. °. If yes, name or water supply Distance to water supply /.cd 9: Is project site near a public sewage collection or disposal system ?..... 0: Name of sewage system /II/ Distance* to sewage system 1. Date observed:_. 23. Name of Health Inspector: Project design flow (gallons per day) ..................... 2. 25. Is State Pollutant Discharge Elimination System (SPOES) 'Permit required? o .,,...� :. -: .�. 4n ... �. �"..�. ....r -: n.:.� • -ai /v^ ^v :_....+,ur �.:. .. .-. r•... ..ev._. ns. v. �:.r. --,. .. .r ..r. ?•-- '�•. -m. .� ....:G+a.� � .� ..cs. ...:....c.. ......•i. <. .. Y- .'. ...a.' .. .n..r�. .0 a� -.:. -..... ....- .a._.r 26. Has SPDES Application been submitted to local DEC Office? ............... 27. is any portion of this project located within a designated Town or State wetland? ................................... ..........................•.... C5 28. Wetland ID Number ..... .................. ............................... _A/ ff 29. -Is Wetland Permit;• required? .............. ............................... . A16 Has application been made to Town or Local DEC Office ?. ................... —A.14 30. Does project require a .DEC Stream Disturbance Pe uit? A/o 31. Is or was project site used for agricultural activity involving application OT" pesticide$ to orchards•or other crops., solid or hazardous waste disposal, . landfilling, sludge application or industrial activity? ......... YES or NO 11%v 32. is project located-Kithin 1;000,feet of existence of abandoned landfill, hazardous waste .site, salt stockpile, landfill, sludge disposal site or any other potential known-source of contamination? ............ .YES or NO _ A/6 DESCRIBE: 33. Is there a. local master plan or fiie•with the Town or Village? 34. Are cow, :munity water, sewer facilities planned to be developed within 15 years? O Alo 35. Are any sewage disposal areas in excess or: 1.5� . 1gPe.'_.`_. - _- _. •. _ . 36. Tax =Hap ID N umber ......... ................. ............................... 231,-3 —I 37. Approved Plans are' to be: returned to: .................. ' Applicant k• Engineer if the application'is signed by a person other than tFie applicant shown in Item.1, the. sW ication must be-accompanied by•a Letter of Authorization: Failure to comply with this provision may be grounds for the rejection °of any submission. I hereby affirm; under penalty of perjury..- that information provided on this form is true to the best -of cry kno►rTe�fse and be 1 ief. Fa Tse sta'tezents ',made herein are pun ishab Ie as a Class A Hisdea,eanor pursuant to Section 210..45 of the. Pena 1 Law. 1 q 3IGNATURES & OFFICIAL TITLES: MillbroUe Office.Centre !AILING ADDRESS: Brewster, NY 10509 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES-, Date Re : Property of /5/NAI,- /AEA,7 Located at (T) 4 .c Sa 4/ Section Block Lot / Subdivision of A6 /0- Z,¢s,pgA%T Subdv. Lot / Filed Map # Date Gentlemen: This letter is to authorize - /,��RY L--/ Al 14,11614 s a;,- . a duly licensed-professional engineer V or registered architect. (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 iu connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, tary Code. Counters is Health Law, and the Putnam County San!- R.A. , #l7 Address kZIV Telephone Very truly yours, Signed 'j Owner of Property yp Address Town 91r - 9i/ - ?Z /x Telephone LAURENT ENGINEERING ASSOCIATES, P.C. -...:, .. .,.., MILLBROOKE'OFFICECENTRE - ... Route 22 8 Milltown Road Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FA)O 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS November 20, 1995 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Tamany Hall Road Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -1 "Proposed SSDS ", dated 11- 15 -95. 2. "Application For Approval of Plans For A Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 11- 16 -95. 4. "Application to Construct ,a Water Well ", dated 11- 16 -95. -... : S. "Design, Data_ Sheet". 6. "Letter of Authorization ", dated 11- 15 -95. 7. Two (2) copies of Residence Floor Plan(s). 8. Money order in the amount of $300.00, review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:bd 95083 cc: Mrs. A. Laurent w /enc.