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HomeMy WebLinkAbout2380DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.15 -1 -4 BOX 20 02380 M, NO NO NO NO 17%. �, , . , ON ��! I i Ir . Is 16 �'1� NO T , I -_ `i 1 .� U jr - 02380 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ® PROPOSAL FOR FOR SEWAGE TREATMENT SYSTEM REPAIR 10 Internal Use Only PERMIT # / , C— (in U U / epair Permit issued in last 5 years ot in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated 1:1 Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION grookSde AvC, TOWN q . TM # �4/Q /J' /J' OWNER'S NAME PHONE # IN-263 - /35-6 MAILING ADDRESS 10575' APPLICANT Name & Relationship (i.e., own r, tenant, c tractor) DATE p� 'g Ftw�i�j FACILITY TYPE est�4 aI PCHD COMPLAINT # PROPOSED INSTALLER /rIG+W 0rA+ SP,-V (rS PHONE # ADDRESS 1MQ REGISTRATION /LICENSE # //_3 Vp--V\, ^ Ai 07q cO)_ Proposal (include a separate sketc locating the house, property lines, all adjacent wells 7�1 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the I, as owner,agree t th ditio stated on thi�fnlm SIGNATU TITLE DATE (owner) 1, the septic installor, agree to co ith conditions of this permit for the septic system repair SIGNATUR . TITLE oa t L DATE (installer) Proposal approved with the folio 'ng conditions: , 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to. be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ Inspector's Signatur Title Defte Exl5iration ate i Re air proposal is in compliance with applicable codes Yes ❑ No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Sheet _J_of t PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLFI SERVICES FIELD ACTIVITY REPORT NAME: f taft ara Tel: AT)T)RF44e 4 I bSrmkslt AVM Pv N (05 -7 Street Town State F Zip PERSON IN CHARGE Name and Title TYPE OF FACILITY: S 5_-f S Rer FINDINGS: - Re-p" r �"^k 4.4. � - KepC;(- a W k fore. , P- (-ompIl'Tt � 13c� Jr WSPFC'TOR , TFT: Signature and Title RFPCIRT RFC'FTVF.T) BY: J acknowledge receipt of this report: SIGNATURE: n') /ne Titles- Sol l Ca a►�0 `c k A [L PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well•.Location - .• :.. Stre_ et.Address: - = I % r ©e Town/Village. ' - Tax Grid # jS� .a I Map , Block Lot(s) Well Owner: Name: Address: Use of Well: 1- primary i,.� 2- secondary V Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock V Othe ,TF711 Casing Details Total length ft. Length below grade ft. Diameter in. Weight per foot lb /ft. Materials: _ Steel _ Plastic _ Other Joints: Welded Threaded Other Seal: —Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed Pumped Compressed Air Hours 7f Yield O gpm Depth Data Measure from land surface- static (specify ft) 3a During yield test(ft) Depth of completed well in feet �00 Well Log If more detailed information descriptions or sieve analyses... are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description = - ft. ft. Land Surface 4 (e 6 (� e afri L If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity ' Depth 170 t Model Voltage HP // Tank Type Volume Date Well Completed T/� �• /a Putnam County Certification No. O o � !V Date of Report S� /� / a Well Driller (signature NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate she(e't/plan. Well Driller's Name ar-, G' 44- tje't' h Address: Signature: 41Amm G1KP&4^ . Date: White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914).. 2.45. 72800 Albert H. Padovani, Director LAB #: 1.001567 CLIENT #: 2500 NON STAT PROC PAGE: l.of 1 ANDERSON WELL DRILLING DATE /TIME TAKEN: 04/28/10 03:40 152 BARGER ST DATE /TIME RECD: 04/28/10 04:10 ATTN: NORMAN, SARAH REPORT DATE: 04/30/10 PUTNAM VALLEY, NY 10579 PHONE: (845) -528 -1491 SAMPLING SITE: 41 BROOKSIDE AVENUE, PUTNAM VALLEY, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE COLD BY: NORMAN ANDERSON TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE ' METHOD 04/28/10 MF T. COLIFORM ABSENT /100 ML ABSENT SM 18 -20 9222B COMMENTS: MFTC Coliform = This result indicates that the water was), (was not) of a satisfactory sanitary quality according to e New York State and EPA federal drinking water standard for this parameter. This comment applies to the Total Coliform test only. THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELA'C, AND RELATE O THES SAMPLES RECEIVED BY THE LAB SUBMITTED BY: Albert H Pa ovani, M.T. ASCP) Directo ELAP# 10323 Putnam County Health Department Water Supply Section 1 Geneva Road Brewster, NY 10509 (845) 225 -5186 ext. 46233 fax: (845) 225 -5418 FAX COVER SHEET DATE: 4/5/2010 TO: Doreen Piacente FAX NUMBER: (845) 526 -8806 FROM: Mitchell D. Lee SUBJECT: Well Application - 41 Brookside Ave. PAGES: 2. (including cover) Should you have any questions or have any problems receiving this fax, please contact me at (845) 225 -5186 ext. 46233. 1 C.I & os AD krioo-7��EO<1?7 i J � PUTNAM COUNTY DEPARTMENT OF HEALTH i- DIVISION OF.ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL I ,, please print or fte Well Location Street Address: Town/Village: Tax Map # 1 Map Block Lot(s). Well Owner: Name: Address: f. Phone # Use of Well: ,/Residential Public Supply Air /cond /heat pump . Irrigation 1- Primary ., Business Farm Test/monitoring _Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought j .. gpm # People Served Est. of Daily usage gal. . Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) deepen Existing Well - Detailed Reason ; ;. _a .. i 4 for.Drilling Well Type r'Drilled Driven Gravel Other Is well site subject to flooding? ..................................................... ............................... . Yes No y _ Is well located in a realty subdivision? .....................:..................... ............................... Yes -.No' Name of subdivision Lot No. Water.Well Contractor: Az,,; � �..e r ? Address: /< � �y Is Public Water Supply available on site? ...... ...:..................- ...... Yes No f .. _ .. Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. i Date: - Applicant Signature: /A/ �;1� n A 17-A PERMIT TO CONSTRUCT A WATER WI=LL This permit to construct one water well asset forth above, is granted under provisions of Article1 0 of the Putnam,Lt County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided bythe Putnam County Health Department. take appropriate action to assure that any and all water and 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. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any revision or alteration of the approved. plan requires a new permit. Well to.be constructed by a water well driller certified by Putnam Co nty. .Date of Issue X J ,/ Permit Issuing Official: / � �:�t�� E� / Date of Expiration _, - _ Title: Permit is Non- Trans able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner;( O'rangelcopy - VV611 driller Form WP -97 Rev. 3/06 ey st-rUATED IN rL o V)LA Y-t �N m -A-r1; co 11, V` F411.;;ED 4N THE• -COUNTY CLERK-S -ND.'.�5?-MAP N'O.' 0 y V -E-E D A i -rQ n �X' IN ACCORD.AtICE \'YITH MINIMUM sTANDARdS FOR TITLE surwEys OF YORK ST:.-E LAND TITLE ASSOCIATION N.Y.C. LIC •# 3618 1 6� -,r . ........... "All certifications hereon are va lio El�)WARD G. P/1,1PIALC701LIC. LAND SURVEYOR for the map and co . pies thereof r-w- 24-BEPIK�?HIRE RD. YONKERS, N-Y.S . ............... if said map or copies Gear the Q•r '....m ....... .t.o• . ........................ 11 .......... -)5e pressed seal of the surveyor wil, ....... * signature appears hereon." r2 \3 171 0. 0 I /k—tOeq V K 'N": I rI S C; A L. E. I v ELEVAT!,)N IN ASSUME[) DATA I 7 CA iA ow o r fi ov Yk e r Y (SLZrC4ar% C*•v•f)ar%y 0j New W S. Sob(t 5O" W. L.,e"•, C), 0 C),— 6) 71 9 7 I'Z 0 %S-Pt.- b jr Tank iiy C� 1- 0 119 dj J1 u > Fields I r2 \3 171 0. 0 I /k—tOeq V K 'N": I rI S C; A L. E. I v ELEVAT!,)N IN ASSUME[) DATA I 7