Loading...
HomeMy WebLinkAbout2160DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 30. -2 -55 BOX 19 PEI 16 p iF ,,■ II 1 1 Ir 7'1� 'T1 • IN Ll I 1 I T, i 1 No - -� a , 02160 Rev. 3/81 1, OF Located ti PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 Engineer Must Provide • P.C:H.D: Permit•q y - - - - -- — AGE Owner /appllcant Name +i Fo erly . MaWng Address Zip it) Town or'Village Tax Map Block 1 Lot 11.1'. Subdivision Name A� Subdv. Lot # 2� Date Permit Issued Separate Sewerage System built by 14% jc"-Q► L*`� - '-V Address —t ovw% rww Consisting of woo Gallon Septic Tank and 333 V h` iq �► �Z Water Supply: Public Supply From Address or: J Private Supply Drilled by Address Building Type t,t tro�,,a't- -Has Erosion Control Been Complet;60 � Number of -Bedrooms Has Garbage Grinder Been Installed? t�V Other Requirements I .certify that the system(s) as listed serving the above premises -were of,which are attached), and in accordance with the 'standards, rules ;and Putnam County D rtment Of, Health. Date JL�1 Certified, by; as shown on the plans of the completed work ( copies nce w1A tk filed plan, and the permit issued by the P.E. R.A. —r �q � !�j !1 , o' �S9 � yV �i 1 Address `Z1Z l \ ' /V�J4,A!1f N� , )RS) License No. 13736 Any person occupying premises served by the above system(s) shall promptly take such action as maybe, necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate iewe►age'>ystem shall become null and void as won as a pubt': sanitary sewer becomes available and the.approval of the private water supply shall become,nuoAMCLvold when a public water-supply becomes available. Such approvals are subject to modification or, change when, In the Judgment of the •C mmissi ner of Health, h revoction, modification or change Is necesuryry. Date lT BY Title III d � x Time z+ t i i Towri) u't . �1 OM (Permttee) 1 �' ............. ' . _ -cam ��lr -vim a WELL CUM.YLL-rtUN K-LrUml DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only TO STRUT ADDRESS: WNIVtLLAGLICIIY TAX GRID NUMBER: }V WELL LOCATION"- WELL OWNER NA ADDRESS: e BIVATE M-1PUBLIC USE OF WELL 1 —primary - 2 - secondary 91- RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm.lNO. PEOPLE SERVED - ---T-y EST. OF DAILY USAGE GD gal. REASON FOR DRILLING ;!f+EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH L_/ _ ft. STATIC WATER LEVEL �s,ft. DATE MEASURED DRILLING EQUIPMENT OTARY O COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING. 9 OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL'LENGTH 4 l ° ft. MATERIALS: Rt STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE Y6 ` JOINTS: ❑ WELDED 19- THREADED ❑ OTHER DIAMETER '� in. :SEAL: ❑ CEMENT GROUT ❑ BENTONITE `® OTHER WEIGHT PER FOOT I!r 1b./ft. DRIVE SHOE-la-YES O NO LINER: ❑ YES 9 NO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES- ONO SECOND HOURS GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE; . DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST It detailed pumping METHOD: O PUMPED tests were done is in- 0 COMPRESSED AIR , formation attached? O BAILIO ❑ OTHER ; ❑ YES O NO If more detailed formation descriptions or sieve analyses 'WELL LOG are available, please attach. DEPTH FROM SURFACE Water Bear- Ing We 11 Dia- Ineter FORMATION DESCRIPTION cane. ft. ft. WELL DEPTH ft. DURATION hr. min. DRAWOOWN ft. YIELD gFm. Sur WATER CLEAR TEMP. QUALITY' O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES ONO STORAGE TANK: TYPE CAPACITY �� GAL. f �. PUMP INFORMATION TYPE CAPACITY 1 11,1 MAKER DEPTH S�pO MODEL f " �(p VOLTAGE.HP WELL DRILLER NAME) Ale APZ�� Q�3 "9// ���/ SIGtlkTTIRE J l� .,` �y 0 6-7 II. IV. V. VI. FINAL SITE INSPECTION Date V In pectecl by ,;CATION VC ` `� - OWNER TM # OR SUBDIVISION LOT # L� I v _ YEr- NO COMMENTS SEWAGE 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' fran SDS area. e. 100 ft. fran water course /wetlands. _ SEWAGE DISPOSAL SYSTEM a. Septic tank size x`1,0001 1,250 b. Septic tank instal evel c. 10' minimum fran foundation d. No 90° bends, cleanout within 10 ft. of 45° bend e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested .r 2. Protected below frost --r' 3. Minimum 2 ft. original soil between box and trenches f. JUNCTION BOX -- ro 1 set g. DIES 1. Len r ired - _f' Length installed,3 ' C=am- 2. Distance to watercourse measured: ft. 3. Installed according to plan 4. Distance center to center A- 5. Slo of trench acceptable 1/16 - 1/32 " /foot. V 6. 10 feet frcm property line - 20 feet - foundations 7. Depth of trench < 30 inches from surface 8. Roan allowed for expansion, 50% 9. Size of gravel 3/4 - 11" diameter ' 10. Depth of gravel in trench 12" minimum ll. Pi ends capped h. PUMP OR DOSE SYSTEMS 1. Size of pump chamber - 2. Overflow tank 3. Alarm, visual /audio 4. Pump easily accessible manhole to grade 5. First box baffled 6. Cycle witnessed by Health De rtment estimated flow pe cycle HOUSE a. House located per approved plans. b. Number of bedroans WELL a. Well located as per approved plans b. Distance fran SDS area measured ft. c. Casin 18" above grade. d. Surface drainage around well acceptable. OVERALL WORKMASHIP a. Boxes properly grouted b. All pipes partially backfilled ' 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 protected & dir.to exist.watercours g. Footing drains discharge away fran SDS area X h. Surface water to i. Errosion control provided on slopes greater than 15 %. 10 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Building F-al L Ht L- O 9= YYl tS Building Constructed by PU -D DI'AC1 S i 2-E T Location - Street PC, T t shill (!AL -,LeY Municipality 1rywr) 'PyArnim f Building Type Section Block Lot 618&) J-s Subdivision Name G- Subdivision Lot # 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 immediately 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 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 Environmental 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. n Dated this i % day of :SEPT. 19, B7 Signature General Contractor (Owner) - Signature O W-REL Corporation Name (if Corp.) TzD -� Do Z-73 igf-3uTUS wPp PUTt4M , VAt -LEP IT:r. - rev. 9/85 mk Titl Corporation Name (if Corp.) Address PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS FIELD INSPECTION REPORT t DATE e b C INSP. BY: a (Name of Owner) (Street Loca ion) NO 4 INITIAL SITE INSPECTION C, 1� i E YES NO CAS Wetlands on /or proximate to property .............. Length of trench measured Property lines or corners found ............. >..... Width of trench average �Z -KNC -t Can estimate house location ....................... Slope of tile line and trench acceptable......... Will driveway need cut ............................ A% Must trees be removed - note these ................ V Deep holes representative of entire SDS area...... �- Additional deep holes needed...... ... ....§a unnecessarly graded............ .............. Sufficient SDS area available considering driveway cut, house location, separation distances,etc... 20 ft. from house.... ........................ Adjacent wells /septics...... � . � . . . .. ...... Distance well to SSDS (ft.) ...................... Number of bedroans checks .................. — ... Access to pLrgMsed well location for drillin ..... Stones, brush, stumps, rubble, etc., greater D.H. - Deep Hole G.W.- Groundwater D.H. 1 Lot 1 D.H. 2 Lot D.H. 3 Lot Depth to G. W. Depth to G.W. Depth to G. W. Depth to rock Depth to rock - Depth to rock 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. Soli Descrimic ..P 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. soil Descr 5oii Descri 0 ft. 3 ft. 6 ft.' 9 ft. 12 ft. 1 A LJEO t t1 DATE: FINAL SITE INSPECTION INSP,BY: YES NO C(1TS 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 .............. Over 100 ft. fran watercourse .................... Natural soil not stripped or SDS area unnecessarly graded............ .............. 10 ft. maintained fran property line and 20 ft. from house.... ........................ Distance well to SSDS (ft.) ...................... Number of bedroans checks .................. — ... Stones, brush, stumps, rubble, etc., greater than 15 ft. fran nearest trench .... ........... 15 ft. of peripheral soil horizontally fran trench ..... ................. >............. Boxes properly set— . .... ................... Could surface runoff from driveway, roads, ground surface, etc., channel near SDS area..,. Does lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE.. �� 1 l �d � PUTNAM COUNTY DEPARTMENT OF HEALTH 1 1 J 3A.86 (, Division of Environmental HesltL Services. Carmel, N.Y. 16512 Engineer to Provide Permit V on CERTIFICATE OF COMPLIANCE�9� CO S lirnm RMIT PAR WAGE DISPOSAL SYSTEM . Located at � tw Subdivision Named Sabd. Lot N Z Owner /Applicant Name Mailing Address �' Vi 61 ati1 D 0\ . CTP04 Building .Type Qr:�t Cty�U14�t8i. Lot Area -lam Number of Bedrooms Design Flow G /P /D Separate. Sewerage System to consist of ��� {Gellert. Septic Tank i To be, constructed by permit . Town or Village T f Tax Map . Block Lot ) I 2 Renewal_ ❑ Revision ❑ Date of Previous Approval Town � �t �'a tvd.. ZIP Water Supply; Public Supply From_ Address ors / Private Supply Drilled by [dress Other Requirements I represent that 1 am'wh011y and completely responsible for the design and location, Of., the proposed system(s); 1) that the separate sewage - disposal system above 'described will be constructed as shown on the approved amendment mere to and in accordance with the standards; rules an regu a ions o e u nam 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 will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any ' part of said sewage disposal system tlurin he period of two (2) years Immediately following the date of the Issu- ance of the approval of the Certificate of, Construction Compliance o(:,the :rig al system.or, any r irs thereto; 2) that the drilled well described above will be located as shown,on�6e approved plan and,that said well will,be.installeC in cc ran with th _tender rules and regu aeons of the Putnam County Del ar men t of Health,, Date Signed _ P.E. u -/ R.A. _ .71 t Address Z _ Ucense No �3731 APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless construction 'of 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 �aq/ new permit. Approved for disposal of domesti sanitary se age nd r private water supply only. Il Date ( _'f/� By _ Title "P1 ,.DIVISION. HEALTH SERVICES DESIGN DATA SHEET- SUWUFACE SFAGE DISPOSAL'SYSTM { FILE NO. owner Address 14- G- , cc,.. Located .at ( Street) . p� ,�..� - ...... � 1 � e . Note N\, &. Sec. N44 .� Block e Lot I k -TL (indicate nearest cross street) Municipality Watershed c� Date of Pre - Soaking S 11 a 5 Date of Percolation Test g HOLE NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fr m beater Level- No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches i 1 2iZ 9. r 2 5 •Z l 2S•� ) � 21 3 � � z .z 2 3 1$ 21 3 Z '4 5 1 r 2 r r 7 ^mil/ NOTES: 1. Tests to be repeated at same depth until appra mately..equal Soil rates are obtained at each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made fran 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: 7- HOLE NO. G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' f� INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED VSous INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: -A _ZEIV7- DATE: S o Q� DESIGN r�Z Soil Rate Used 10 Min /1" Drop: S.D. Usable Area Provided 5000 No. of Bedrooms Septic Tank Capacity 1000 gals. Type Calicoua& i Absorption Area<Provided By 333 L.F. x 24" width trench NEW oF �,.. I I Z^ICI" . - -- ry� Name Ze',U, Signature Address `,2q: Z N1k_ SEAL N(;Iom lilt /117- 10516 �9�0'0• 43736P���2 PROFESS�O� THIS SPACE FOR USE BY HEALTH DEPARDENr ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PU NAM COUNTY DEPART OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT DATE REVIEWED.- BY: _ (Name of Owner) (Street, cation) DDS Permit Application Corporate.Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc :Hole Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Contours Existing & Propos d brivewgy- & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewa e & Expansion Area Expansion Area shown; a y o uff. size If Pumped Pit & D Box tailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees .201. to Foundation Walls'.. 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' from Foundation 50' to Well 15' Well to PL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same r b ©_ Mks SO =VIA Imm == =no mm W. -MM _MM mm on ffnm WIAM .s DDS Permit Application Corporate.Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc :Hole Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Contours Existing & Propos d brivewgy- & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewa e & Expansion Area Expansion Area shown; a y o uff. size If Pumped Pit & D Box tailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees .201. to Foundation Walls'.. 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' from Foundation 50' to Well 15' Well to PL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date �IrSI`aJr. Re: Property of ��o onaS �i- ul�ol -*es Located at �a}��;.. �r- Q��. ��1�rN F00_ Em .\ (T) t'.A . �k� Section "� Block j Lot j) -1Z Subdivision of l9ett��lX�k2 1���0�15 1 1 Subdv. Lot # 26 Filed Map #` y2,so A Date 7 1 I .i Qi Gentlemen: r *' +L4 This letter is to authorize �.• �• a duly licensed professional engineer ✓ 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 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, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, Signed Countersigne Owner of Property CMC P.E. , R.A. , # 437A CN) ' Address III N� S�- Address Telephone to (ao3 Town c[ A.- t 3 b a Telephone SEPARATION DISTANCES :IN FEE Vs Caun D.ep ment. oP R tiDt Div Gsion Of Evvironment al Health 5ery cee 40, 04'elff at notod, Pdr co.rif a & WItb 4,011 eble Rulesr and Regal 0 g they 19, Kdvath F aw wo 0 f? AS -BUILT SEPTIC PLAN prepare d for THOMAS- HOLMES tDdIiVG ST. SCALE: 1'= 5O' TOWN OF PUTWAM VALLEY 9/29/87 PUTNAM COUNTY* MY ' M... .B... I Lice` 3 '� 4 5��'6 7 i i8 f 9 ��.`�0' 'i4 , 12 'i !3 Vs Caun D.ep ment. oP R tiDt Div Gsion Of Evvironment al Health 5ery cee 40, 04'elff at notod, Pdr co.rif a & WItb 4,011 eble Rulesr and Regal 0 g they 19, Kdvath F aw wo 0 f? AS -BUILT SEPTIC PLAN prepare d for THOMAS- HOLMES tDdIiVG ST. SCALE: 1'= 5O' TOWN OF PUTWAM VALLEY 9/29/87 PUTNAM COUNTY* MY ' M... .B... I Lice`