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HomeMy WebLinkAbout2205DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 39. -1 -6 BOX 19 02205 114, 1 ,_ 02205 M U DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 B. Tracy PO Box 37 Cold Spring,. NY 10516 Dear Mr. Tracy April 17, 1996 BRUCE R. FOLEY, R.S. Acti6g Public Health Director Re: Addition - No increase in number of bedrooms I have received and reviewed the plans for the proposed addition to the above mentioned residence. ^The proposal for the addition has been approved as per plans bearing the latest revision date of April 17, 1996 and this Department's approval stamp. Based'on the information submitted, the above mentioned addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained.. <. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of.the applicant and the jurisdiction of the Town of If you have any questions, please contact me at your convenience. RM /jp cc: BI (T) Putnam Valley Sir erel y, Robert M6rris, P. E. Public Health Engineer 4 c*rtify. "Of Which. e: 4 �. of �X. 'F t t Al ILI 4� 1 2. 0" V W N ... .... Guam County 'Clf:EnvirOnMentai R 94 ealth SOrvic,�,. 14 ipprovfd as t PO ed for oonfOrlkance with Wlf- ble ,Holes; V. am County lv� W. tire , Title - - T"'t 77 J7 ENGINEER ;MUST . PUTNAM COUNTY DEPARTMENT OF HEALTH pROV I DE a a rOfvi3ion of.:Envrronments/ HealN► 511,, , Cann% N Y 1 12 PERMIT CERTIFICATE ;OF, CONSTRUCTION COMPLIANCE-, F0W,StWAdE ,DISPOSAL'. SYSTEM 4. Town or Village _ Located .at ._ _• -. `� . , Tax_:ifap 'Block Owner �� /rJ Q �A �7/i � / .Formerly Taz M_ap Lot'q: % : 'J.: Subd `Lot q J Separate, Sewerage System built by Address ` Consisting 'or. a lo' cial. Septic Tank andp� Other requirements Water SuPply: Public Supply From, Private. Supply ,Grilled ay : • J` l dressoQv/ �7� ko Building Type r c, No., of Bediooms Date Permit Issued His Erosion Control .Been Completed?. 'Has garbage grinder been. installed? I certify that the syetem(s) as listed serving the above premises were constructed essentia egg own qri the plans of the completed work ( copies of. which are attached), and in� accordance with the standards', rules and "regulations in r (1cT,. he filed ,plan, and the permit issued by the Putnam County Department Of Health . ` r Date Cert` fed by W_ P.E. R.A. ( / c Addrett o * �'�'° ns ,t .v'f4 License Ad. s v his Any person. occupying' premises served, tly the ove systems) shill promptly take we IM ;as n�1 ssaliy o urs the corredlon ;of ,any unsanitary contlitions resulting from, such usage ;App val of the Separate saweragesystem sh m ull tindwoid� ai a public •sanitarj.s$Wor becomes available and the approval of'the private water supply shall,bscome•null and-void Whe ,vvdt�}�fu�yati'becomes availabb. Sucli approvals are sub)ecC to ;,modification •or change when, >in the'7udgment.•of the Co ssio r of FI yN.w x, atfbn; Yt�otlIflution or.change.,Is necasw►y. /,/ Oa i ��pp cCn�O Date .L / Zq F . / �• By TItN :Rev. 6/85 M DCHD -W'WC NELS COMOnL ETHON HEInO5 :AFFICEUSE• ONLY r' -` GROUND ELEVATION NYS ° E ` ft. DUTCHESS COUNTY 0 HEALTH DEPARTMENT ^;,• 22 MARKET STREET, POUGHKEEPSIE, N.Y. 12601NOr; GRID : N WELL COMPLETION DATE (914) 431 -2044 F} §iJDRCE —_ PLEASE PRINT OR TYPE -- .- SLOG - - WELL LOCATION STR DDRESS: A GRID NUMBER: D � TELL OWN ER NA ADDRESS- D d.S ®� PQIVATE ❑ ? BL•LC USE DE WELL -9 RESIDENTIAL ❑ _UBLIC SUPPLY, ' AIR /CON . /HEA UMP ABANDONED 1 - primary El BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify) Z - secondary p INDUSTRIAL ❑ IBSTITUTIONAL ❑STAND -BY ❑ MOUNT OF USE YIELD SOUGHT __6� gpm. /N0. PEOPLE SERVED `�`' / EST. OF DAILY USAGE gal. REASON FOR NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑TEST /OBSERVATION DRILLING ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ®� ft: STATIC WATER LEVEL ft. DATE MEASURED DRILLING CK, ROTARY ❑ COMPRESSED AIR PERCUSSION ❑DUG EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION. ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING .OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH ft. MATERIALS: aSTEEL ❑ PLASTIC ❑ OTHER_ LENGTH BELOW GRADE ft. JOINTS:. ❑'WELDED 19 THREADED ❑ OTHER CASING DETAILS DIAMETER '' in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE ;OTHER WEIGHT PER FOOT Ib. /ft. DRIVE SHOE: BYES ❑ NO [ LINER: ❑ YES NO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST ❑ YES ❑ NO DETAILS SECOND HOURS GRAVEL SACK GRAVEL DIAMETER TOP BOTTOM ❑ No SIZE: OF PACK in. DEPTH ft. DEPTH ft. WELL YIELD TEST If detailed pumping �� ��� If more detailed formation descriptions or sieve analyses are available, please attach. METHOD: ❑ PUMPED i tests were done is in- `<COMPRESSED AIR , formation attached? DEPT SURFACE H FROM water Bear- Well Dia- ❑ BAILED ❑ QTHER ; ❑ YES ❑ NO in9 meter In FORMATION DESCRIPTION CODET. ft. ft. WELL DEPTH DURATION DRAWDOWN YIELD Land urface 0 r ft. hr. min. ft. gpm. IF AVAILABLE, PLEASE COMPLETE: WATER ❑ CLEAR TEMP. QUALITY ❑CLOUDY HARDNESS r.. ❑ COLORED ANALYZED? E S ❑ No ❑YES ❑ No ANALYSIS ATTACHED? ❑Y SITE MAP: A SITE REAP MUST BE ATTACHED SHOWING LOCATION OF ,!!DELL AND DISTANCES TO AT LEAST TWO LANDMARKS AND ANY POTENTIAL POLLUTION PUMP INIPORMATION �/ SOURCES. DATE TYPE CAPACITY MAKER DEPTH / WELL DRILL NPME /S ADDRES / r� ATURI . MODE VOLTAGE HP /0 .� s PUTNAM COUNN DEPARTMENT OF HEALTH- .. _ DIVISION OF ENVIRONaWAL,HEALTH'SERVICES Owner or Purchaser of Building Section Block Lot 41 Building Constructed by RTC . 20.1 UTti to ti Location - Street Subdivision Name PU r+ tA e;,!I Municipality Subdivision Lot # Building Type GUA WqM 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 .d :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 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 19 Signature P- LI"1-J Title Genera Contractor (Owner) - Signature Corporation - rev. 9/85 mk Co�poration Name (if Corp.) b 13o-.Y Address I r s Yorktown Medical Laboratory, ��� LAB d CA. 005699 � - 321 Kear Streee Date Taken : io Z3 .Yorktowp H0ghesQ N. Y. 10595 0 Time s lD 3C� _�. . Deste Rc d .� �►� Time ,., ._ . .. a ... (914) 245-3206 D`� R "gio°ed i OCT: 2 7 g Director: Albert H. PadovaniM. T. (ASCP) Collected By: 6AVFjFy7 Referred By: vt `%Q� Sample Location: Kirk L Phone :� 777 7D Phone a Sample Type: Repeat Test? !'(check one) able Non - potable STP INF _ STP EFF ® Other: LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA v_ Standard Plate Count (CFU /1.OmL) (Agar Plate @ 35 °C) MEMBRA FILTRATION TECHNIQUE (MFT) f _ Total Coliform (CFU /100mL) 6 Fecal Coliform (CFU /100mL) Fecal Streptococcus (CFU /100mL) MOST.PROBABLE NUMBER TECHNIQUE (MPN) Total Coliform: MPN Index (per 100mL) Fecal Coliform: MPN Index (per 100mL) OTHER ANALYSES REMARKS (For Laboratory Use) Sample Status: (check each). Outgoing ® Na2S203 Incoming LE 4 °C _ GT 4 °C _ Other: KEYOR TERMINOLOGY RDS = Recommend Disinfec- tion of Source TNTC= Too Numerous To Count CON = Confluent'( =TNTC) LT +�. Less Than (<) ' . GT =, Greater Than (>) N/A Not .Applicable T,V a T.P_fan them nr Prgujkl t® THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASH °T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE Ed ORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTEDO AT-THE TIME OF COLLECTION. 12 /85(RvsdT /87)RWE For Lab Use Only:_ H/C to LAB OFFICE HOURS Win Lab ➢'s .; . 9 — 5PNio. Non.—Frio 9AX =EOONo Hat. I ;n'— '"-^- i uxx�: ,,—r 7`^, ri 3� !�c-^• L t1. * L,�^�5 +-- ,� 1 y " i PUTNAM COUNTY DEPARTMENT OF HEALTH eer'ao Provide Permit Al ev`" 3186 Divlelou of Envbronmental Health Services Carmel N Y 1051? Eng� �� o G : ° on CERTH7CATE,OF COMPLIANCE�j� CONSTRIICTION PERMIT FOR SEWAGE" ISPIOSAL SYSTEM Permit N •, , I Located Subdivision Name ' tibd:'Lot # — .: Tai: Block Renewal 7 ❑ o Reon Ownei /Appllcant Name 'O �/� =�Ca t°�P % ❑ oiPrevious Approval= ell Mulling Ald dress / ��' °' Town Zlp ^ %IG (-/CI l Lot Area Fill Section Only Depth" Volume S LrG Numbeg �Pe , + D r of Bedrooms � �� � esign Flow G /P /D �• � � , PCHD Notl6cadon "is Regnireil When le completed:; c - Separate Sewerage System to rnnelet of dG UBaDon, Septic Tank'fmd ✓ .� i! To be constructed by Address wit�r,Sappl Ilc`Snpply From Address on Prlyyaf�e Supply, D;in� by _Address Other Requirements "may' 9. represent the am wholly and completely responsible for -the design and location of the proposed system() ► . 1► that the ,separate•sewage disposal system abov "scribed will be; constructed as shown on the approvedyamendment there to and:,in'accordance wir,'- eastartCandgg►�ules.an . regu a �Ons o o ' .0 nam 'County' Department o ' \Health; tand'thi t on completion thereof a.!'Cert�ficate' of'Con ;truct{ori 66i 'a satisfacto ys o the Commisilonei of Healthwill be submitted to the Department, and" a .wntten' guarantee will be furmshed.thgowner his supeessOis, heir } °o`� tstpns�D�,the•buildei that,said builtler will Place : :in--.990q. operating condd�o'n any ':part of said sewage' disposel system during the peiio0 "of two'(P) esr, immadiStelY� following the date of,the'issu- ance`of the;;approval of the Certificate of 'Construction. Compliance of. the-original system Orsn repairs thereto )�hst fde defiled well described above will De'I ated as shown on the.epproved plan and that said well will be i n acco' dsn yr th Re stantlardf "rulef aiPd, ipgu a'TiTns: "of. the Putnam County D Paitment`of.Health•" i i ' r'. i 1,ia� r �,"t, Date SignedC�!L % / -' L' m �i6 PE R.A. o/ ; c,�sv) , �, w y.,s "' Address 1 •� z tJ2ense No APPROVED "FOR CONSTRUCTION his approval expues. rom the. date issue unless scohstr "uctior)fthe building hai7been undertakeniand is revocable fora cause or•'may be'ame d oumoditied when considered ne essary'by the ommissioner ofgMealth:, .F�nsi.rCAlige or.altoratbn of, construction o..i of cr: "a,trx y. . reQuires'a ne ermit, AP roved forlQdis%pR� sal of; tlomesfic samtar sewage d /oi prwate' water supply �Taw4 ir" ynu/�/� Date' (r% �� , -Its By / IzaiM Title_a�y / /IJ'. II. IV. V. Vi. Od- FINAL SITE INSPECTION Dote ° j A Insr tEd by TM # R SUBDIVISION LOr # - - - YES S SEWA DISPOSAL AREA a, SDS area located as approved Tans `" ! x b. Fill section - Date of placement 2:1 barrier .. LGTH WIDTH AVG.DPTH c. Natural soil not stri do Stone, brush, etc., qreater than 15' from SDS area. e. 100 ft. fram water covrsp w tlands. S&QkGE DISPOSAL SYSTEM,,," ", a. Septic tank size T 1,000 1,250 b. Septic tank installed le, el c. 10' minimum from f un#tion J d. No 90' bends, cleanout within 10 ft. of 45' bend , e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested 2. Protected below frost 3. Minimum 2 ft. original soil between box and trenches f, JUNCTION BOX - properly set ' g. TRENCHES 1. Length requi red - Len installeff / S� 2. Distance to watercourse measured'. ft. -% V 3. Installed according to plan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 " /foot. 6. 10 feet from property line - 20 feet - foundations 7. Depth of trench < 30 inches from surface ; 8< Roan allowed for Sion, 50% 9. Size of q ravel 3/4 - 11" diameter 10. Depth of ravel in trench 12" minimum 11. Pipe ends capped h. PUMP OR .DOSE, SYSTEMS I. Size --of - - chamber...... 2. Overflow tank 3. Alarm, visual /audio 4. Pump easily accessible manhole to grade 5. First box baffled 6. Cycle witnessed b y Health Department estimated flow per cycle ; Ic HOUSE a. House located per approved plans. C J b. Number of bedroans WELL a. Well located as per approved plans b. Distance from SDS area measured ft. C. Zg's'ing 18" above grade. d. Surface drainage around well acceptable. OVERALL WORxiw%SHIP a. Boxes properly E2uted r (� b. All pipes partially backfilled c. All pi s flush with inside of box R d. Backfill material contains stones <•4" in diameter j ✓ e, Curtain drain installed according to lan ✓ e,cx a f. Curtain drain outfall rotected & dir <to exist.watercours g. Tooting .drains discharge away from SDS area h. Surface water 2rotection adequate i> Errosion controi provided on slopes greaterthan 15 %. 11 '., *•,mss -:ws^, a.:.?'.. -•^ - r:,r —. CONSTRUCTION PERMIT FOR SEWAGE < PUTNAM COUNTYDEPARTMENT OF HEALTH � .� 11 Dlvlsiori of EnvlromnentalHealth Services Carmel N Y 10512 �° ?Engtoeer to Provide "Permit N r / r ion CERTIFICATE OF COMPLIANCE Pein It N DISPOSAL SYSTEM Y = 41 Town or illage Located at , Sabdlvielon Name •ra Lot q `� Ta: Map Bloch Lot' L. �J ,enewa1_ ❑ Revision ❑ 4. Owner /Appllcattt Name / W A" C% a ti`s Date of Pr ivfon Approval MaWng Address Town 7 a Z(p / o s� fe Building, a C^ Lot Arolt - / 2 �" " Fill Section Only Depth r Voimne i Ll ,. Number of Bedrooms ;Design Flow G /P /D .. �dQ PCHD'Notiflcatlon Is Regalred When F1111s'completed Separate Sewe "rage System to corselet of Gabon Sepdc Tank eud 4 To W constracted by Address Water Sappl} Pab11c SapP1y;:From Address ' ors Piivote „Supply l)rliled by_ _Address - Ottier Regdlremente I represent that -1 am wholly and completely responsible for ,the design and location of the proposed syste'm(s); .1) that 'the separate sewage disposal .system • , uct t . ,. , . les an regulations of a” U ram above -described will betonstructetl as shown on the.approved. amendment there fo antl +n 6cco "rdance w7th tie standards ru County" Deoarfinent..of- >�Health' and'theYOn comolet�ortther eofa•" Cert+Licateiiof.•Conitr`uction Compliance . �satisfbctory :to`,tfie,Commissioner of�Heelthwill place 'in good_ 6perat4ng c6r -ante of tho-approval of,'the will be located,as shown `on tt County Department of + all Date. APPROVED FOR CONSTRI revocable for cause or_.rt1ay b .requires a new' permit. - Ap IDate W ition any.:part ot51said sewage' tlisposai', Certif+cati of, Construction Compllance; approved plan and that said wail will be ii t i Signed . c Address TION Xhis approval expues o �'l amended or mod+fied6when'consiX, dh� ovetl for disposal'lof `domeatic'sandary;,- At �., ;ner; his; successors, heirs or assiyns.tiy•the builder, that said builder will 'ftie perjod of two,(i, years immediately following the date of the issu- 1',system or.any repairs thereto; 2), that the'drilled well described above ordance wi x the 8ndards, r I ' es and' 'regulations f the Putnam h • .. P.E. R.A. IifIVA. License No' �t struction of'the. building has -been'. undertaken and is s Commidsionei 'oi Health: Any`crange or alteration of construction 1p riv to water. supply only ' /gip VIE Title DEPARTMENT OF HEALTH >' r 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 treet Address fop Town /Vil age /City Tax Grid Number �..� G' e4d WELL OWNER Name rr. �✓ frr Address /d S7 rivate eG /� O i3" �" a�/ e�"DPublic USE OF WELL 1 - primary 2 - secondary SIDENTIAL 0 BUSINESS 0 INDUSTRIAL ®PU LTC SUPPLY Q AIR /COND /HEAT PUMP O FARM 0 TEST /OBSERVATION 0 INSTITUTIONAL ❑ STAND -BY ❑ ABANDONED 0 OTHER (specify El AMOUNT OF USE YIELD SOUGHT ,�� gpm /# PEOPLE SERVED .4t /EST. OF DAILY USAGE ,!�� gal REASON FOR DRILLING [KEW SUPPLY. ❑ PROVIDE ADDITIONAL SUPPLY ❑ REPLACE EXISTING SUPPLY ® DEEPEN EXISTING WELL 0 TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE L!PRILLED ®DRIVEN ®DUG ®GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES P" NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: f '40 ,0 GeV,, s Lot No. WATER WELL CONTRACTOR: Name O/rsy&n / pq j ey'_�v,a Address : Z,1 _f 0'-" � IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: DISTANCE TO PROPERTY FROM NEAREST WATERA MAIN: a TOWN /VIL /CITY LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ,31x-9_,4r7 ®ON REAR OF THIS APPLICATION ®ON ARATE EET date) sign to e 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 Date of Expiration: a 19 a m ssuing Official Permit is Non - Transferrable 8/86 Re: PUTNAM COUNTY DEPARTMENT OF HEALTH DTVIS3-,ON- 0'F-- EN- VIROIVMENTAL -�HE LTH-SERVIC•ES Property ofc�0a. ✓s� Date % e-1 Located at ZLIL—e- -3l ). Section Block % Lot - Subdivision of, /.47 Ctr-'7 /a,-'j�� Subdv. Lot # Filed Map # Date Gentlemen: ; This letter is to authorize — a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit fora separate sewage system, to i 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 connect -ion• with- -thi-s- matter and to- -sup�ry se­ the -construction of said. n 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. 4 Countersigned: Very truly yours, Signed Owner of Property Address Town, 718 Telephone PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENrAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS ... : r,. PERMIT REVIEW SHEET - CONSTRUCTION PIT - - - -- - -- - -- - - - ...;.....: r DATE REVIEWED: .- =�E. BY: (Name of Owner) (Street Location) �^ Permit Application e�•t21Vt_ rJL ion 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 Syst r vity Flow Fill Profile D nsion Volume D or J Box;Trenc details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area Expansion_Area;shown °gravity.flow,suff. size If Pumped Pit & D Box Shown & Detailed 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. 4'10; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' 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' fran Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same PUrNAM OOUNTY DEPA17Il= OF HEALTH - DIVISION OF awmonqNTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET - :EONS7('�tUCTIQ(V. PERDU T. m-� DATE REVIEWED: BY: ' (Name of Owner) (Street Location) • �� _©_0 mm MM MM S� 0� --*"; %11M ©M ®m MM Sol SAM F == NEI M -M no .DOCUMENTS Permit ApplicationQ� Z- 7-E3(o 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. e D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Two -Foot Contours Existing & Proposed �1-6VO Driveway & l es Cut Footing /Gutter Curtain Drains Perc &;Deep Holes Located Representative of Sewage & Expansion Area Expansion,. Area; shown ,- .gravi.t_y..-flow,suff... -.size..: . If Pumped Pit & D Box Shown & Detailed House _ No. of Bedroams 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 _PL. Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 1001 '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' fran Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On' DDS Plans & Permit Same N ` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH ' SITE INSPECTION - REALTY: SUBDIVISION f =n=y -=1 Tnfnrmnf inn Month Day Year Proposed Name: ;�, _ � , U - . - -Zate _ Location: ��� (T) (V) County )istance to: Public Water Supply: —�-�-� Public. Water System: tent of Buildinct Construction: None .Other Describe: 107 VAhD4;% PE` M Topography and Other Special Features Site Description: Hilly ./� Rolling Steep Slopes _� Gentle Slopes Flat gatercourses On or Within 100 ft. of Property L� Any Impact on SSDS' s Yes "No Swampland: Yes No V-_ Approx. Percent (if Yes) % In Flood Plain: Yes No 3odies of Water Drainage R.O.W. Needed gatershed: Yes No _� Any Regulations Applicable �xtensive Fill /Cut Necessary ' <% � A. ias Any Area Been Filled: Yes. No ✓ Fill Material Condition Soil Observations ;oil Type: Gravel / Sand Silt _ ,��- Clay . Hardpan Rock Outcrops )bserved Fran: Backhoe Excavation Other: 2>0 (p ' ;oil Percolation Test_Witnessed: , Yes No Results min/id min/id min /in :_�....:... _ , - ............. _ ....w.. _D _ _ . Month -w - ..Day.. -Year - .... 4i.nimum Estmated Depth to Seasonally High Groundwater '� 47 Date (Use if site inspection :vidence of Mottling: Yes No Depth 7 7*14 04- (performed 7/1/ to 3/14) I!ill natural drainage be altered or require special lave previous sections been approved: 1 (relocation, filling, etc.) Yes No Ultimate Design to be a -lots :f ultimate design is 50 or more, has variance application been made: -4es — - - . -No -- . - - -- , )oes proposed subdivision involve public water.supply: )ther remarks 7)eW*6'1�W 1P O LIV) r Yes No Tie0AK/11%1S1PR)M(1t OT Inspected By: a Acccnipanied By: - I a SEE REVERSE SIDE FOR TEST HOLE PROFILES tel: DEEP HOLE PROFILES Name: Date: •G D.H. -Deep Hole. G.W.- Groundwater D.H. Lot D.H. Lot Depth to G.W. _ _... _ - Depth to"G' W De th to G.W. Depth to rock Depth to rock Iptri _:to rock. T Soil Descri tion 0 ft. 0 ft: 3 .ft. 3 ft. 9 ft. 1 I 9 ft. 12 ft<1 12 ft. D.H. Lot °° D.H.. Lot Depth to G.W. Depth to G.W. Depth to rock Depth to rock Soil Descri tion Soil Description 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. D.H. Lot Depth to G.W. Depth to rock Soil Descri tioi 0 ft. 0 ft. 0 ft. 3 ft., 3 ft.„. 6 ft.. 6 ft. I 6 ft. 9 ft. 9 ft. 9 ft. 12 ft.. 12 ft. 12 ft. D.H. Lot D.H. Lot D.H. Lot Depth to G.W. Depth to G.W. Depth to G.W. Depth to rock Depth to rock Depth to rock 01 3f 6f 9f 12 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. Soil Descri 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. Soil f PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .. .. ... , .. . ,< ... Ya . ...._ . Date ..., -.. ' 3�','��� 6 . ,.: , .,K: • • . ... ,. , . ,,. . Re: Property of Located at '3 e "' (T )/ �/' '� _Section Block / Lot1� f _ Subdivision of Subdv. Lot # Filed Map # Gentlemen: Date This letter is to authorize U5� �h�/ j�✓% a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit fora 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 syst•em-v- or-- systemsr- irk- c -onfor mity with •the pro vision's• •of Articke• '145 - or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, of F S i g n e Coun ersi �i�ge $ Own o Pro ty 1 Address d. . •,- � timid ,F �cav,: �� Address "e > >..£ r,m y �� Town A Phone Telephone' . ��sy . PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services AFFIDAVIT CORPORATE, OWNER ARP.LWATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: (Z U represent that I am an officer or employee of the corporation and am authorized to act for having offices at Whose officers are: President: Vice—President: Tr) Secretary: s . Trea ur Lr. Name of Corporation) /v A; ;Name and Address Name and Address and (Name and Address L, 'y' 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: A7 of 199 Title: L,Wtar Public Lisamarie Bernazzani Notary Public, State of Now ya* Qualified in Mstchester Courity No. 4815725 f-A 8 �k Term Expires March 30, 19 & RN PUTNAM COUNTY I)Ep'r- OF HEALTH Corporate Seal" PUIMM_ CQUWT DEPARTMENT OF DESIGN DATA SHEr- StJF3St)FA,CEr.SFWP�GE DISPOSAL •SYSTEM ...._ _ ..FILE N0....._.. _ Owner . " / ",, "e. G- Address Vi" Located at (street) J7 C°i �G�/t Sec. / Block �_ Lot .� % (indicate nearest cross street) Municipality Watershed �rr,rr►r*rn wrr+cr avDr.rrnrrrrwc Date of Pre- Soaking Date of Percolation Test SOLE 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 1113 �> </ 4 . 5 3 4 5 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 suhnitted 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 'PEST HOLES DEPTH HOLE N0. % . HOLE NO. ? HOLE NO. G.L. ..... ._.� K �_. �c� < 2' r/ �r. ¢� �Ledr, vv a��i CilG1�f All i 3 4° 5° 6 ° 7' 8° 9° 10' 11° 12° 13' 14° INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED © ty INDICATE LEVEL TO WHICH WATER LEVEL.RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �� ��`�"�: DATE: DES,1GN Soil Rate Used _ P j�Min /1" Drop: S.D. Usable Area Provided No.. of Bedrooms Septic Tank Capacity /C,�c gals. Type�s�„ r Absorption Area Provided By � L.F. x 24 " width trench Other � la�'F�/Y i /� .`cal ..! '/7 /;.��' Name Address a BY HEALTH DEPART ONLY: Signature 245v- coo r</ Soil Rate Approved sq.ft /gal. Checked by Date ,ir nmf Wg RiLl ­gg, ld MIM "Thin is -to c6rtAlf- •wl constru4tea Us 1:• d o.l tti.,, k ar. 2 d t]'t t the".6kite c,,-rercd. over. Tk VIC 'all sta'ndax 6-4 OF NEW tE Al an, p 46 lg� VII 51, ..... . al� - ...... . . . . . . ,ir nmf Wg RiLl ­gg, ld MIM "Thin is -to c6rtAlf- •wl constru4tea Us 1:• d o.l tti.,, k ar. 2 d t]'t t the".6kite c,,-rercd. over. Tk VIC 'all sta'ndax 6-4 OF NEW tE Al an, p 46