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HomeMy WebLinkAbout2159DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 30. -2 -54 BOX 19 02159 Al r r. mi � % , ■ 0 him, 1L 1 , rlr S. .., 02159 PUTNAM COUNTY HEALTH DEPARTMENT o. DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR YES N Internal Use Onl y � N,�M- - 0 ❑ d Repair Permit issued in last 5 years of in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. /Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION ����% S % �q,,� y� / %y may_ TM # OWNER'S NAME (:J-o 2 `!l 0&;47,j PHONE # $ �S Zz --S 25-7 MAILING ADDRESS �a 3a %'u D D is ✓G - 5 7 ; �%�✓ Val! 1- /0S-?l APPLICANT 0 w r✓-e ✓� Name & Relationship (i.e., owner, tenant, contractor) DATE 5131 �� FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER /77- o Saw PHONE # ADDRESS REGISTRATION /LICENSE # '"'Y >0576, 7 9r H 736 PO /v PoG ( 7 Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. I, as owner, or repo d agent of owner agree to the conditions stated on this form SIGNATURE TITLE Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in ac rdance with the above proposal and conditions. Proposal Approved Proposal Denied Inspector's Signature & Tie Da COPIES: White (PCHD); Yellow (Town BI); iPihk�(I Jstalle) Orange (Applicant PC -RP 99ML Rev. 8/05 DATE �/3� 16 O 4!��i w\ �eJ ?z AS BUILT DRAWING �--- -- It (� (S�Vec�.w�F%� RD✓� Leonardi & Son Construction, Inc. Date: 6 Carolyn Dr. Cortlandt Manor 10567 (91 4) 736 -9010 4W FAMPTIPOR --oA f PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use "I- VZU -0+ WAR ❑ Repair Permit issued in last 5 years /Delegated ot in Watershed P Y Re air within Bo d's Comers, W. Branch or Croton Falls Res: ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review n SITE LOCATION � ?07- V'y'➢ 1)jvJ(,, S% - AUT�V,�,., yd¢ #cy _Ny- TM # Qm OWNER'S NAME CIO e- /0 d t14;�✓ /PHONE # S C/- = Zz 253 MAILING ADDRESS ,I 3a r'y a L/ ST %7✓,14, V*//-,Ll o S 21 APPLICANT J c. ,����' v 0 Li �-e Name & Relationship (i.e., owner, tenant, contractor) DATE 513( w7 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER PHONE# ADDRESS (p Ci��l �G�i� i� /�. Cy�r:12�'�'''� REGISTRATION /LICENSE # Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 2 00 feet of repair and the location of existing and proposed trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. _ I, as owner, or repo d agent of owner agree to the conditions stated on this form SIGNATURE �- TITLE Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number c. Location of installed components tied to two fixed points d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in ac rdance with the above proposal and conditions. Proposal Approved Proposal Denied 3� ®g Inspector's Signature &Tie Da COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 DATE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address Located at (Street) Tax Map 3O Block 2 Lot_; y (in 'ate nearest cross street) , l 405< Municipality U All?m VQLi Watershed UOS O N SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test :;:: D epth �i!afer Water ud From Gro n L yel e Percola tit tt T►nte Eta se Time �1YIEn) surface ()finches) T?ro In pp Rate Mole No Rats No Start Stog : Start Staff Inches M nfInch 1 2 3 kam 4 5 f 2 o+�;;oS • y 3 4 1 5 J 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLIES DEPTH �_JHrOLE NO. HOLE NO. HOLE NO. G.L. 0.5' G'i 0 // AUA 1.01 � 1.5' 2.0' 2.5' / 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date P% Design Professional Name: Address: Signature: Design IProfessioanal's Seal ►J Page No. - of Pages LEONARDI & SON CONSTRUCTION, INC. OWNER: LOUIS LEONARDI 6 CAROLYN DRIVE • CORTLANDT MANOR, NY 10567 (914) 736 -9010 LIC. #WC- 3112 -H90 • WC- SEPTIC LIC. #00067 • LIC. #PC -560 (CERTIFIED) PROPOSAL SUBMITTED TO PHONE �- -- ... - -- DATE /Z D . © STREET Z— JOB A1v1E~ CITY, STATE and ZIP CODE cj JOB LbOATION ""--' — ARCHITECT DATE OF PLANS JOB PHONE we hereby submit specifications and estimates for: i'� 1ry .................................... ............................. ............................. ............. .......................... ................. ................:............ ........................................... ............ ....................................................................................................................................................... ............................... :................... :o..:......o ld'.................... . ........... ......................... ................... ...................................... ...... . .............. ............. ........................................................................... .... ..........................._...V ............................... . . .......... . . . . ............................ . . . . . . . . . . . . . ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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'.... -..... 1.0......... arc. �.....:.. ��- 6..... ......l�.r....d......- ...�,...- ....:...... v. �. �. r5 .................... ............................... PLEASE NOTE :....... ..........•SYSTEM'LIDNGEVrTY"IS' NOT 'GUARANTEED'UNLM'DESIGNED'BY"A' LICENSED' PROFEESIONAt -ENGINEER:•.................. ................ .............................. : ............. ............................................ -TANK TO BE PUMPED BY OTHERS AND PAID SEPARATELY.- -NO LANDSCAPING RESTORATION, OTHER THAN GRADING DISTURBED AREAS, IS INCLUDED UNLESS SPECIFICALLY STATED.' We FropoSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars ($ ). Payment to be made as follows: E CHARGE OF I ' ADDED CUSTOMER IS RESPONSIBLE FOR ANY AND ALL COLLECTION FEES. ALL DISPUTES ARE TO BE SETTLED THROUGH BINDING ARBITRATION. All material is guaranteed to b6 as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Authorized Signature involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents fire, tornado insurance. Note: This proposal may, be or delays beyond our control. Owner to carry and other necessary _ ___,_ , _�_____.:__ _..____ withdrawn by us if not accented within days. Our wurKars am imry covered by wvmmuana wu,NvnsauG„ n,au,a„rv. Arreptanrr of Props 0 1 —The above prices, specifications and conditions are satisfactory and are' hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature CERTIFICA OF CONSTR,U E PUTNAM COUNTY DEPARTMENT. Of HEALTH Diwsio- of. Environmental Health Services, Carmel, N. Y. 10512 'ION. COMPUANCE FOR "SEWAGE DISPOSAL SYSTEM dd . I - Town or village Located at /V/ " 14 Owner Separate Sewerage System built by Consisting of Gal. Septic Tank _ Q Other requirements Water Supply: / Public Supply From // /] �! Private Su I Drilled By u� n "'r � Section i_5 Block Lot Job Address lineal Feet X -3 idth trench Add r s -n Building Type c1 No. of.Bedrooms Date Permit Issued Has Erosion Control Been Completed? I certify that the system(s), as listed serving the above premises were constructed essentially as shown on the plans oft a completed work (copies of which are. . attached), and in accordance with the standards', .rules and regulations, plans, filed, /a6he permit issued by t Putnam County Department of Health. J i P.EZF2 A. Date ertified by F � I Address License No., Any person occupying premises served by the: above sys m(s) shall promptly take suchaEtion as may be necessary to c re the correctio��of any unsanitary conditions resulting from such usage. Approval of the separate .sewerage system shall become null and void as soo as a public `sanitary. sewer becomes ; available and the approval of the private water, supply shall become nuil.and void when a public water supply be es available. Such approvals are subject to modification or change when, in the judgment of the Commissioner' of Health, such revocation, di ation or change is necessary. ?, A Date I. / BY _ � Title x+791. 'YORKTOWN MEDICAL. LABORATORY INC. P.O. Box 99 321. Kear Street.'. 245 -3203 Yorktown Heights,. N:Y..10598 DATE COLLECTED RESULTS OF EXAMINATION OF WATER )WNER DATE RECEIVED HENRY RUDOLF 10/19/7 ',ITY, VILLAGE, TOWN VOR NAME OF SUPPLY DATE REPORTED PUDDING ST. PUTNAM VALLEY, N.Y. >AMPLING POINT WELL - - -- LOT 5 -- 3ACTIrRIA PER ML. (Agar plate count at 35' C): COLIFORM. GROUP (Most( probable No. /100ml.) HARDNESS, TOTAL - ppm 9 LESS THAN 202 )ETERGENTS - ppm NITRATES (as N) -, ppm IRON, TOTAL - ppm, 'LOURIDE (F) - mg. /1. these results "indicate that the water was US of a satisfactory sanitary quality when the sam le was collected. (ASC A. H. P.ADOVANI, M. T. P) V41E.LL C.OMPLET(ON REP013T PUTNAM COUN "iY DEPARTMENT OF FlEAL1'1 Division of Environmental Health Servicrs COUNTY OFFICE BUILDING • CArvAE.l., NEA' YORE This report is to be completed by Jell driller and submitted to County Health Department together with laboratory report of analysis of water Sample indicating water is of satisfactot y bacterial quaiity before certificate of construction compliance is issued. i REPORT MUST BE SU31`091TTED WITHIN 30 DAYS OF WELL .CONIPL ET ION i OWNER ADDRESS t " LOCAT_.ON OF \'JELL / (No. b Street) Town) (Lot Number ;P' � �1 � f �Q,•��� ) -- �f,�',j� ± �a` �4:L vJ�.._..�C�- �� e ^ j—j BUSINESS 110 :PROPOSED Ini DOMESTI ESTABLISHMENT FARM TEST \YE'.I. :% USE OF WELL PUBLIC AIR OTHER ❑ SUPPLY El INDUSTRIAL CONDITIONING 11 (Specify) DR R!L Q (SpHEyEQUIPAFNT ROTARY L/X.A PERCUSSION a PERCUSSION ) CASING DETAILS -- - - — LENGTH (foot) Lh DIAMETER (inches) C '/ WEIGHT PER FOOT ((�� DRIVE SHOE �, i ii11 THREADED u -T — — WELDED R.-YES . LJ NO WAS CASiNi5 GROUTED? �i YES L___i f\O I ' YIELD TEST (� HOURS G.P.M. LJ BAILED El PUMPED LFS COMPRESSED AIR G' YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE- STATII,(Specily feet) DURING YIELD TEST fleet) Depth of Completed Well in fee! below land surface: / MAKE OPEN TO AQUIFER ( leaf) SCREEN ' — �LENGTH DETAILS SLOT SIZE DIAMETER (inches) Diameter of well including IGP.AVEL SIZE (inches) FROM (teat) TO (leot) IF GRAVEL gravel pack ( /aches): DEPTH FRCM LAND SURFACE - Sketch exact location of w�alf with distances, to at less( _ FEET to FEET FORMATION DESCRIPTION two perntan ^.n! landmarks. - if yield was tested at different depths during drilling, list below FEET -- GALLONS PER MINUTE •- DATE \YE COAiP ETED ���"•'a' DATE: OF REPORT JWLELL 0544,LLER (5ignatum.j� r� • ..._. -� �� !! FA' P �• Neer or Pu c a er Building Municipality Building Construct -d by Section 4- 0/0 Location - Str et Block Building Type Lot GUARANTY OF SEPARATE SEWAGE- 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 guaranty to the owner, his succes- sors, 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 initial use of the sewage disposal system, or any repairs :Wade by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occu- pant of the building utilizing the system. . The undersigned further agrees to accept as conclusive the de- termination of.the Director of the Division of Environmental Health Ser- vices 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 �p day of 193 Signat Titl VN co oration, give name and add ss) - - - - - - -- - - - - - - -C - - - THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMP�jETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILL NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health r�.z. -�u-.• - -'-- �, -^t,�'-, _T'"`i..^'_*'v-rr -� _ 1 y-'. - .,..'....'..i1'T +C'.�-}�.z..�•+, �C t.ci..c. .p .:. ..,!.- ;•- -fl - y ��� PUTNAM COUNTY DEPARTMENT. - OF-. HEALTH bivision' of Environmental Hea /ih Secwces Carme% .N Y::,10512 CONSTRUCTION PERMIT FOR SEWAGE': DISPOSAL SYSTEMS t�.t11�1 V>!IL� "" Town or illage � tom. I r D A• te Located at r ✓ h �l '�'. Section U �1 J Block .Subdivision z..� Lot "' - Job' . Owner_ 0 Address GO c Buildin9'TYPe- ::F-- i\i..; Lot Area y��., ). r Number'of Bedrooms Total Habitable.Space L�� Square Feet Separate Sewerage System to consist. of Gal. Septic Tank lineal feet .X width trench. To ' be 'constructed by !ac>.v-5. Address- Water 'Supply: ublic..Supply From . Frigate `Supply to be drilled by l� �'� r V -'t Address Other„ Requirements I represen t that l am wholly and completely responsible for the design antl location of the ,proposed - systems) 1), that the. separate: sewage disposal system . ,.., ?? , . a m above ,described' will be constructed as shown on the a roved amendment.there to and m accordance;wtth the standards; rules an r u a sorts o e. • u n County, Department of: Health;, and .that on completion thereof a "Certificate of Construction Compliance "`satisfactory to the Commissioner of Healthwill be submitted to' the Department, and "a Written guarantee wtll be furnished the owner, his successors heirs'or assigns. by the builder, that said builder will place' in good operating . condd�o`n} any "part of said sewage disposal system during the period of.two',(2) years imrnediately following thedate of the issu- ance of the approval. of the 'Certrficate of Construction •Compliance of ;the original - system or.'anyxepairs.thereto;,2)'that the drilled well described above Will be located as sha on the approved plan and. that said,well wilt be installed t accordance, with ,the standards, rules and degulat�ons of . the 'Putnam County 'Depart ent f Health Date 2. i n CJ.L., ',p.E. R.A. Address' ~ License'No. ` APPROVED FOR CONSTRUCTION 'ThiS_approLal expires one year from the, date issued unless construction the building has been undertaken and Is revocable for cause or may be'amended'or modified when considered necessary by the Commissioner of Health Any. ;change or alteration of construction requires a new permit ..'Approved for '.disposal of domestic sanitary sewa a and /or private water. supply only, Date!!?`L��i`/ 7 `.�s BYv " `' S� / �'� Title �`7— 1. -3� l +"", is J 1� d4 w ra PS '*r ',`'tt - ;�u. :+ y -e. +. ::y _ .,t .. r t € §• C s+ Ya £ 1 r r kk Y r �' r Yx a. r'+ r .a - E t H r w 6 j' y "`' , L i r Y x£ V .� r '� 4 t 1 + T 3.:�'s a -t, L oa "t-1 -N x . 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'. a _ . {:• f,< _�.. ,.: 1 r , r t \ f �, 1 s . ,,. -. PUTNAM COUNTY DEPARTMENT OFJEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE .NO 51 Owner ^ ,u'z k Q, 7 o; G4- Address lW6 Co ? � 1 (C7 r •T- Located at (Street). Vok)D1 o(;, S i Sec. Block , Lot n i.ca e nearer cross s ree Municipality__ \)djt=La Watershed CCC) :W�, SOIL PERCOLATION TEST DATA REQUIRED.TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Water Level No. Time From Ground Surface in Inches. Soil Rate Start -Stop Min. Start Stop. Drop in Min. /in drop Inches Inches Inches: l 41 t C1t ;L" ►+ '+ jS? L 5 1 � . 2 3 5 Notes: 1) Te'�ts to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. A11 data to be submitted for review. 2) Depth measurements to be made from top of hole: i DEPTH G.L. 6" TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. 0 HOLE NO. HOLE NO. 18" 24" 3 0 11 36►► C,u- 42 n 48 5411 60" 66" 7211 c? . i 78►• 8 4 if AV INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY ,, 1, c` " S-- Dates DESIGN Soil Rate Used ,-_b Min/1 "Drop: S.D. Usable Area Provided Illy No. of Bedrooms ;� Septic Tank Capacity � r^ 1p S Absorption Area Provided By ';'�c>�L.F. x24 "QT=�k h trenc Tyner Name o4 ' —i) A, K-uA-i--Y J �', igna u . ,. Address if) A A` '-E— C L r THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved �'���� Sq. Ft /Gal. Checked by Date P I . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date AA /�, 2 C \ -A Re: Property of F: ti;1Q�;� c �_ Located at P Sa P_&E T Section rj Block 1 Lot Gentlemen: l� \ This letter is to authorize a duly licensed professional engineer or registered architect (Indica e ..+:;. -'" to apply for a Construction Permit for a separate sewerage syst' to serve the above noted property in accordance with the standards; rules or regulations as promulgated by the Commissioner of the.Putnam County oeatlicpartlJGllt f nii, and to sign all ne(:e�3sary papers on my behalf in 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. the Public Health Law, and the Putnam County Sani- Counte�rsignod�: P.E �< ress Q,r NEW � Telep one (Seal) Very truly Signed