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HomeMy WebLinkAbout2392DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 42. -3 -11 BOX 21 No is A if Lr ��- - - .- . 02392 P C ARTME FHEALTH 1� te.V, `3/86. D s I.Y. 10512 I/ -lb Engineer Maet Provide P.C.H.D. Permit N— CERTIFICATE O CONSTRUCTION OMPLIANCE FOR SEWAGE DIS SAL SYSTEM - - - - -. �iG/T ,r C owe or VIII Located at A . T P p Lot Owner /applicant Name / erly Subdivision Name �" IV. Lot # Melling Address `' �"��' 71 p_ f0 Date P t Issued y Separate Sewerage System built by / G 01 &44_1_C4& Address Consisting of _—Gallon Septic Tank and Water Supply: Public Supply From Address ore Private Supply Drilled by -46 hl O/! Address yr' 7%0 ow Building Type Has Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been installed? �d Other Requirements �� yo A W , I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work f copies of which are attached), and in accordance with the standards, rules and regulations, in acc he filed plan, and the permit issued by the Putnam County Department Of Healthy. of W Date 6/ T / / Certified by P.E. ftIe R.A. Address 2,07 a' z26 / JLlcenso No.'Z7�S Any person occupying premises served by the above system(s) shall promptly take such ac me a cures the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage system shall b null Vold n as a publ%. unitary fewer becomes available and the approval of the private water supply shall become null and void whe ones available. Such approvals are subject to modification or change when, in the judgment of the Commissioner as th, Ification or change Is necessary. / Date - Title a pUTfUM CODMR DIWAZIW=I' OF KEALTH b Pwt ldu Iw" / ;, �\ t�\ DhYI� d �I W Ha116 Saiet�loa. Cnsel. p.Y.116U e� CERTW LATE Coll p g of (77-7o — ezol FOR SEWAGE DEPOSAL E LfeatMi at � t 9n awn or VOage 71 Selorle"a Nelms G / —Subd. Let / a' Tau t3 ' Block 3 La V Renewal_❑ Rev1d= ❑ / Date d Peeviooa Appaovd m•�s Aa�e.a O/ e a,.e ov Ud !!Tow. a � 1 6,43 47 Dame Subdivision &_Rkoved %a Z/ % )Fee Enclosed Amntmt- s Type G; S J G�Grf O L Lot Ana /. 6 2 �/dc FM Seedon Only Depth _3 -' voblme Neaubee d Ee a Dealgo Fk►w G P D 6o O PCHD Notification la Required When Fib hi aempleted Sepaeale Sewee.a Srb>• to eenaYt of /O0 O Gallon SspdL Twit L % D Zq " t:,,.5 Te be eaob.oted by '- Address Water Sttjjlpbt jablle Sup* Feem AddIrm set haeab Samb DdBed by --Add i other 13 1—,; 1 1 represent that I am wholly and completely responsible for the design and kxation of the proposed System(s): 1) that the mperate SaW di sal s stem above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ns o County Department of HMlth. and that on completion thereof a ^Certificate of Construction Compliance" utisfscto a Commisooner of Healthwill be submitted to the Department• and a written guarantee will be furnished the ownsi. his successors. heirs or af� • that said bulkier will pgee in good operative condition any part of sold sowage disposal system during the period of two (t) yell$ a fp1 A the date of the Ism- amt» of the approval of the Certifkte of Construction Compliance of the original system or any repelrs t well described above well be located as shawtt oh the approved plan and that Mid well will be Installed in accordance with the Ste and r of the Putnam County Department of N"Kh.. Date S nod Gr ! ^ Z R.A. Addre 2 APPROVED FOR CONSTRUCTION: This approval expires two y rose the date issued unless const ction' pS n undertaken and is revoceble for ca so or may M amenda0 or modified when consid ed ury by t mmisooner of Health. ,.. Pe' ation of construction requires a gppr_ed for disposal of domestic sa age, and/ water supply only: ' •;',!' 9 IQ� Rev. rArlo ly Tit 10 88 °ice le Owner or Pqtchaser of Building VA Building Constructed by Location - Street Municipality Building Type lkelk" C -OF HEALTH � Jv Section Block Lot �U /e� M C' Subdivision Name Z Subdivision Lot # GUARANM 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 wi.th 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 fiCat .Qf.:.,C;�7`Tistrgctioki Compliance" for the sews a dis sal_. star or an . Certr_ g_ �.P�? ....'.. �. X'. 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. Corporation Name UT Corp.) Dated this day of 19� Signature Title iera Contractor (Owner) - Signature Corporation Narde (if Corp.) ,412,E -/ Address rev. 9/85 mk -LI6;1- r% 1' . Address bS i C WELL COMPLETION REPORT : ►z Office use Only DEPARTMENT OF HEALTH -:iM.visi�ti' -Uf -Env roii�enCal °iiealriki' Servi'c'es ' PUTNAM COUNTY DEPARTMENT OF HEALTH STI 'AOUAESS: W t ly odfdai TAX GRID NUMBEA.' WELL LOCATION WELL OWNER NAME' Aooaess: 8 P8IVATE 110 PUBLIC USE OF WELL 9 RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED 1 - primary ❑ BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify) 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY p MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED % EST. OF DAILY USAGE .kO gal. REASON FOR .REPLACE EXISTING SUPPLY ®TEST /OBSERVATION []ADDITIONAL SUPPLY DRILLING []NEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL DEPTH DATA ° WELL DEPTH ft. STATIC WATER LEVEL ft. DATE MEASURED DRILLING ig ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH 6 fL MATERIALS: 0 STEEL O PLASTIC O OTHER CASING LENGTH BELOW GRADE _ ft. JOINTS: ❑ WELDED ® THREADED O OTHER DETAILS DIAMETER �" in. SEAL: 19CEMENT.GROUT O BENTONITE DOTHER WEIGHT PER FOOT /L Ib. /ft. DRIVE SHOE EYES O NO LINER: O YES ® NO. SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? FIRST QETAIkS _ ..._ — ❑ YES ONO-_-r_ . _... - SECOND" _ _...z _ ... _ . _ HOURS GRAVEL PACK ❑ YES GRAVEL DIAMETER TOP BOTTOM ❑ NO SIZE. OF PACK in. DEPTH ft. DEPTH It. WELL YIELD TEST If detailed pumping tl`t ELL LOG if more detailed formation descriptions or sieve analyses METHOD: ❑ PUMPED t tests were done is in- are available, please attach. t DEPTH FROM Water Well O COMPRESSED AIR , formation attached? SURFACE. Bear. Oi3- FORMATION DESCRIPTION caoE O BAILED O OTHER ❑ YES D NO It tt ing in WELL DEPTH DURATION DRAWOOWN 11PEmL . Sorlace / it. hr, min. It, . WATER CL EAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE PUMP INFORMATION CAPACITY GAL. TYPE CAPACITY WELL DRILLER NAME MAKER DEPTH ADDRESS 13 4Z SIGM4URE MODEL VOLTAGE HIP ` . " YML ENVIRONMENTAL SERVICES ' 321 Kear St�eet Yorktown Heights, N.Y. 10598 (914) 24,-5-2800 ' ` Albert H. Padovani, Director ' . LAB #: 87.302652 CLIENT #: 5491 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~-~~~~~~~~~~~~~~~~ ' BELMONTE, BlAGIU � DATE/TIME TAKEN: 09/22/95 10:30 4 SEIFERT LN. � � DATE/TIME REC'D� 09/22/95 11:47 PUTNAM VALLEY, NY ' 10579 � REPORT DATE: 02/18/97 U � ' PHONE: (914)-� 526-3893 SAMPLING SITE: SAME KITCHEN TAP SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE COL'D BY: 1ASIO BELMONTE � ` � ' TEMPERATURE..: { 4C NOTES...: COLlFORM METH: -MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD ` . ` 09/25/95 MF T. COLIFORM ABSENT /10O ML ABSENT ` COMMENTS: ` BACT THESE RESULTS INDICA*[ETHAT THE,WATER AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING �Y~THE NEW YORK S[ATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. / . . ' . . SUBMlTTED BY: -------- _ 4e7 _�_------ A I bert H. Padovani, M.T.(ASCP) | I)irec+or ELAP# 10323 ,k 1, PUTNAM COUNTY DEPARTMENT OF HEALTH 1. . . . . ,.. . .___.... .1 ON,- ,0 En •.ALTx SERVICES:.::-„ .,.. Date Re: Property of 9146/l 94 Located at 5 t.- //­`;L_i�-<� (T) ts�yj �Irl t� Section 4-3-49 Block 3 Lot 167 Subdivision of D11�if�� �' �U ��� !��✓�i C Subdv> Lot Filed Map # 2-Z70 Date lo - Z i -•S7 Gentlemen: This letter is to authorize a duly licensed professional engineer 6Xor 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 . - �= co znecti�ri with -this - � iatte - -and to s°upervi. e "'the• construction -of ...s•ard 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. e,4 Countersigned: P.E. ess 5 � '/1_/ 4 Very truly yours, Signed 6�4� Owne of Property 3 % 50 Address �]f ! % 0 j a Q Town Telephone 9 Telephone 3 \Ij.a '• ..4 5 1 2 3 4 .5 Notes: 1j -Tests to be repeated at same ,depth until approximately equal soil rates arexobtaingd'at each pPrcol3t test hole. All.d4ta to be submitted for,'revie�rt a ;Depth, Imc sure) n,t's b mad2 from too of . hole . .. t .WESTCHE:S'PER OOtfiPPY QEPAR' MENT OF HEALTH „ Bureau of EInvironlnental Quality 19 .Bradhuo:t;. AYfnue . „ fiiag4 -ho �, New York 11.3532 OE$IGN DATA SHEET - SEPARATE` - SEWERAGE SYSTEM' FILE NO. Ad3ress 3 3' 6 Sri .� RioC, o�s,rii 6'" Owneri O i1o1G Located at (Street) 5e Sec. --k3 Block .3 Lot J� In, ioate nearest cross St.) Municipality Watershed PBROQGATI!q'1 TEST DATA RBQUERED'-TO -BE.•SwNTTI'6D APPLICATION 4901- ��'�^J /j��'' .HOEB # azm TIM. P.ERON ATION Death ! to Water Water Level Soil Elapse . -From Grd- Surface In Inches Rate Hole Run Time Start Stop Drop Min /In Nnmber.. ;>No, -S,tart Stop Min. Inches In' chest In Inches Drop ,. pF NE4y,Y pANCI$ QQ 3 \Ij.a '• ..4 5 1 2 3 4 .5 Notes: 1j -Tests to be repeated at same ,depth until approximately equal soil rates arexobtaingd'at each pPrcol3t test hole. All.d4ta to be submitted for,'revie�rt a ;Depth, Imc sure) n,t's b mad2 from too of . hole . .. t aorna�eoao wvaaae aissf.omamaaeoe va ^�– trn-.� �L d cam. SE dBB to nriia 8 .� 'W ®1� CON9129CBM Fm SWAB ONFOUL ST52M 77�^ Cn a SdONTUM Nam r a, , , / ��,� Sb& HM B Z yob 3 Riga ❑ o �/ MEMO— U� j" maiRms fib/ 7Utj atrJ Oir !�r 17!It' 8owo /U C� G•,� � 2Rp /D 5 -747 Date Subdivision ARBroved Fee Enclosed Amntint Rzefts TYPO �'- 5 �_ -,, r Acz / �. 0sue,� " �� 9ro r WG9 cIP D Gov F §a &Gwdmd Vn=FS b TO Lei Gamsomatod by AAA on V rdwaft St'p Dd d by Addrem Odw 0 r6psetan2 that 0 am Who0ly erad Coawpmately Pete' -0610 for tho design W4 location of that p7eia,at :d tystaff4ab . 11 that the teperate tewa dit Deaf E wont above described will be constructee at Shown on the approvole amowwwnt there to and in accordsoco With the Standard aeu Dons ® ha *V D"Wt mt o9 tkuni% a" that on eowepbtion thwoof o "Cettifirato of Construct.180 Compluaned• mtist 0/ tnitatonm of MeaftlaysM Be eabmitted to the Wpdrttwewt. and a anitbtt IUMawteo will be furnislpd the owlW. his iutoMwe. heirs or "IW tMt tale hulloes wool OCOCC In flood aperatbq oowdRiow OW part of told mumm a disposal system during the paaiod of two tsl s tlleIWO of the Soup. rhea of the of the Cwtifte®to of Construction Compliance of the original system or env ma 0 doom IMS a� VW be loeatod ea WASMI'w M ttta epprove9 OM MW that mid wM will be htstallag In acom dWWD ankh too Me N the P#Av mm Ctll•�q 6l�s9t of C�'3�BS �� _ a6�pmcvao Grow COmT51uCYlCOi. Phis approome capb©t t road the "0 ism ianom cCm1WoCB1ow '.�z ui � w uwCatatt€n 000 66 ed tr rocaloto for cawae or nww be anedo or ified whoa can by t 04mRIR lon of ooncerucktoo bbci o c��wa e� Ooo 46e90n 00 ®oa:oels � woCoOG7 GROV' Q r :; DEPARTMENT OF HEALTH Division of Environmental Health Services .4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 p:•.:..:: i:• APPLICATION 'TO " ; CON STRUJ 7, ;�A' �WATER� WELL::. - :.�.:.. ;...... < .. -..... � J. /�. PCHD PERMIT 0 WELL LOCATION treet ddr ss Town/Village/City Tax Grid Number ), ;/ e- 115 .F. - 3 - �-0 WELL OWNER Name �- �'d Ma }' ling Address o Gjo L��'Private / �o 4 Amo�Gt� O Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL O BUSINESS 0 INDUSTRIAL. 13 PUBLIC SUPPLY' QAIR /COND /HEAT PUMP OABANDONED O FARM O TEST /OBSERVATION O OTHER (spec ifq M INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT 5""gpm /# PEOPLE SERVED -�4 /EST. OF DAILY USAGE j!!!�d gal O REPLACE EXISTING SUPPLY O TESTY OBSERVATION GI ADDITIONAL SUPPLY JUNEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL REASON FOR DRILLING .DETAILED REASON FOR DRILLING WELL TYPE ,DRILLED DRIVEN DDUG OGRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF'SUBDIVISION: Vp Lot No. 2 WATER WELL CONTRACTOR: Name //1 r12d>d�Ies$O/'7 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ENO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY 'DISTANCE TO PROPERTY FROM NEAREST k'ATER MAIN: - - LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED RON SEPARATE SHEET (da e) signature) 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 manner as not to degrade or other ' contaminate surface or groundwater. Date of Issue: J 19 Iq '-'/ &4v Date of Expiration 194¢4 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW, SHEET: for- ,CONSTRUCT PERMIT NAME OF OWN _ Loom STREET LOCATION = _ - BY DATE SJ N TAX MAP DOC ENTS. M_"� DISCHARGE (OK) ��ERMIT APPLICATION PERC & DEEP HOLES LOCATED r i PC-I- m REPRESENTATIVE OF PRIMARY AND EXPANSION WELL PEF-'vllT;= PWS LETTER = EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE' ENGINEERS AUTHORIZATION = IF PUMPED PIT & D BOX SHOWN & DETAILED �ESIGN DATA SHEET(DDS) = HOUSE - NO. OF BEDROOMS EEP HOLE LOG = WELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM CONSISTENT PERC RESULTS (3) = PROPERTY METES & BOUNDS PERC HOLE DEPTH m HOUSE SETBACK NECESSARY (TIGHT LOT) EICORPORATE RESOLUTION = HOUSE SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE PL&NS THREE SETS = NO BENDS; MAX. BENDS 45 W /CLEANOUT' m HOUSE PLANS - TWO SETS FILL SYSTEMS VARIANCE REQUEST =CLAYBARRIER GENERAL m10 FT HORIZONTAL: SLOPE 3:1 TO GRADE LEGAL SUBDIVISION m FILL SPECS m SUBDMSION APPROVAL CHECKED =DEPTH GAUGES m PERC RATE �— `� — 3 m FILL PROFILE & DUYIENSIONS =ILL REQUIRED / = VOLUME CURTAIN DRAIN REQUIRED TANDPIPES TRENCH X- APPROVAL SSDS ADJ. LOTS =LFTRENCH PROVIDED m WETL.ANTD (TOWN/DEC PERMIT R & D) =60 FT MAX CD DATA DDS PLANS & PERMIT SAME = PARALLEL TO CONTOURS M PRE- 1969 - NEIGHBOR NOTIFIFICATION =I 00% EXPANSION PROVIDED m LETTER BUZBA SEPARATION DISTANCES SPECIFIED ON PLAN Ml 00 YR. FLGOD:ELEVATION� =;��_ FTELDS __.. REQUIRED DETAILS ON PLANS _�- M 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF 1 IL m SEWAGE SYSTEM PLAN - (NORTH ARROW) 20' TO FOUNDATION WALLS m SSDS HYDRAULIC PROFILE m GRAVITY FLOW []] 100 TO WELL, 200' IN D. L.O.D., 150' PITS m D/ J BOX= TRENCH/GALLEY= P- PIT DETAILS m 100 TO STREAM WATERCOURSE LAKE (iNC.EXPAN) CTJ SEPTIC TANK - SIZE, DETAIL Cl7 50' TO CATCH BASIN, 35'.STORMDRAIN, PIPED WATER m WELL DETAIL, SERVICE LINE IF OVER CI7 10' TO WATERLINE (PITS -201) m CONSTRUCTION NOTES (GRINDER RATE) m 50' INTERMITTENT DRAINAGE COURSE DESIGN DATA: PERC AND DEEP RESULTS = 200 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS TWO -FOOT CONTOURS EXISTING & PROPOSED SEPTIC TANKS DRIVEWAY & SLOPES CUT 10' FROM FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS WELLS ED 15' W E LL TO P.L. COMMENTS: PC -1 PUT NAM COUNTY D E PART M E NT OF H EA LT H .Iv:t, .....�.. w�,.i `: r.- :r.��:._' u._.,uv _.f..r r.u.. a. .,t,�;isw r•.. l..:vv�x...��vn <.. -rte`: _. na .. e.v '. .. .r: ... •f,. ..n_..... :�r�r.. ..r�y� ..r Y�r..4.._r. _. :•.n:.e iw� �, ra:...W w..a�Ytmtrw. w,.•q. APPLICATION FOR APPROVAL OF PLANS FOR AlWASTEWATER DISPOSAL //SYSTEM 1. Name and Address of Applicant: 2. Name of Project: 3. Location T /V /C: zctl y 4. Project Engineer: Gj,/1��i'✓/ 5. Address: mO' /✓� License Number: a y�l��� Phone: 6. Type of Project: ;-Iprivate /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? iVv Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ...../1.0... 9. Has DEIS been completed and found acceptable by;Lead Agency? .....7 .... 10. Name of Lead Agency .... ,S area -under .the-control of local. pl °aniii.ng; �-�oning, ' . _. ._ ........• . or other officials,'ordinances? y 12. If so, have plans been submitted to such authorities? .................. e,5_ 13.'Has preliminary approval been granted by such authorities?.)/ e-5 Date Granted:f21�9 % 14. Type of Sewage Disposal System Discharge...... Surface Water A'*" Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ............ ..........�.................... 17. Is project located near a public water supply system? .........!V.d..... 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collectionlor disposal system ?..... itib 20. Name of sewage system Distance to sewage system 21. Date test holes observed: 22. Name of Health Inspector: 23. Project design flow (gallons per day)........ ..? �.b ........................ 11/93 C. 2. a 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. tu'e 25. Has SPDES Application been submitted to local DEC Office? ............... 26. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... JV o 27. Wetland ID Number ......:................. ............................... -° 28. Is Wetland Permit required? .............. ............................... Has application been made to Town or Local DEC Office? 29. Does project require a DEC Stream Disturbance Permit? /loo 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO �o 31. Is project located within 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,0 DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ........... 33. Are community water, sewer facilities planned to be developed within 15 years? : -34._. -Are any sewage disposal areas,1n__e.xcess, of 15% _ slo. pe ?............................ 35. Tax Map ID Number .......... .........................� -✓B -. 36. Approved Plans are to be returned to: ................ Applicant 'Engineer If the application is signed by a person other than the applicant shown in Item 1, the application 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 my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 290.45 of the Penal Lair. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: F 10 �` ' E a/ PcnrMM COUMY DEPAMMi4P CF HEALTH DIVISION CF -HEALTH SERVICES DESIGN DA`14A $i l�SJBSUFAiCE SF TALE "D SPC 1L SYST .- LAN - -Owner ' -1°/�-�' �! c I /S - _ - Address ' E i `' -f `, � -? a-� .:. located at (Street) �'�� ILS �!-1 L,.�: - o1��.dt v .- _ La . :Block `Z = hot (indicate nearest cross street) Minicipalitye (�j`� f A�.L i.f Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBNIITIM WITH APPLICATIONS Date of Pre - Soaking &L)(,A. Date of Percolation Test HOLE r NtP�F�t QACR -TIME PERCOLATION Run Elapse Depth to 'Water FYcm Water Level - - -- No. ...... __:...._Ground Surface, In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min/In Drop _..... __ _.._..; .. _- Inches Inches Inches 'A ' 4 - t a J, -2 . 35 b • 4s Lo -�... S -4 , ..�_. _ 41..6o .- I5 [o u �. .L -� (rte __:_.._ .. .� ....__..... Z ........._/2— , .. _........._ .... -.. I h 4o D/In �._:.. . o _ 2 ' �; 35 u:.b; to ..:� `10 ;.:.._. tDZ, y :'3. t� ?_ y., - ... 4 7 00 �� �s� s __ 4 =j :s �n 2 y 'Z Z a I h 1 4 7 ;eta 5 M.,,..,.. ,.. s" 8 a... _ v_ •.'3 u . cj' i h 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 suhmitted for review. :_ ... 2. Depth measurements to be made from top of hole. rev. 9/85 n TEST PIT DATA REQUIRM M .PE. -. %TI'S APPLIC RTION DESC:RITION OF SOILS ENO IN TESL` RODS LA 8° 91 10° 11° 12 l4 °- �4as4 _ INDICATE LEVEL AT WHICH GftOC DWATER IS ENOOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING MMUNT= c� DEEP HOLE OBSERVATIONS MADE BY � ,Ei U,&12AF��g DATE: o DESIGN Soil Rate Used -Min /1" Dropa - - = ' S. D. Usable Area Provided =� No. of Bedrooms - Septic Tank Capacity 1 ©D C� gals. Type GoN e Absorption Area Provided By -L.F. x 24" width trench Other A� 0 Name aiz�Q C l9 Sigm Address THIS SPACE FOR USE BY HEALTH DEPARDENT ONLY: 60753•% Soil Rate Approved sq.ft /gal. Checked by Date