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HomeMy WebLinkAbout2450DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -1 -11 BOX 21 02450 J I �` r ' �`' II L IF' 4 rV 02450 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ° CL PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR 10 / Internal Use Only PERMIT #/ ❑ . El SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT Repair Permit issued in last 5 years IS bt 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 Al j7 TOWN v . (!/��� TM # (� /77 ZT(atd(�tG PHONE # 9 %y'lAf Yaiz Name & Relationship (i.e., owner, ten on ractof) DATE '7_2-o -7-0Cl FACILITY TYPE SOS PCHD COMPLAINT # '"'v PROPOSED INSTALLER 20r„/ 4-�, --Z'- PHONE # ADDRESS a� a10 %rdsa�✓ 20 _ /si,�ec.6f REGISTRATION /LICENSE # looms' Z%oI 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 system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. I, as owner,agree to the conditions stated on this form SIGNATURE - TITLE DATE % ,ZP- 2,cj W (owner) I, the septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE , / /,,,r/te DATE 7 °Lu'70 (installer) Proposal approved with the following 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. IM 1 r-nNAL U,C UNLY Proposal Approved Q Proposal Denied ❑ -71a 0111 nspector's Signature & Title Dat6 I / Exp ration Date Re air proposal is in compliance with applicable codes Yes No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUTNN.A.M COUNTY DEPART -MENT OF HEALTH DD-ISION OF ENNVIROLN-NIENTAL. HEALTH SERVICES DESIGN DATA SHEET -'SUBSURFACE SEWAGE TREATNMEINT S YSTEN4 Owner: Located at (street): Address: FIV? TNI M" Section. Block Lot ?Y[unicipality: ?-OTAIA-At. ",Lrz-�K Watershed:- SOIL PERCOLATION TEST DATA Date of Pre-soakin-. 5 Witnessed by: – Date of Percolation Test:, Hole -.-No Run No, Time, Start Stop Ela pse . Time (min.) Depth to water from ground surface (in't hStoin Start 'p 'W"ater level drop. inches Percolation Rate min/inch 2 5 2 3 4 2 3 4 2 4 1 T-IZ m -Ir ;;-,P 1L'N- 24-2;0 J1 03:4 GPM FROM- ENVI RO NMENTAL HEALTH ;84¢''i9.11 T -062 P- 002' /002''.: F•114 :.�.. Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTfD DIVISION OF ENVIRONMENTAL HEATLII SERVICES FIELD ACTIVITY REPORT AT)DRFS4: /Q/ BEtk &gki -041 MUAIy A&Z, Street Town State Zip PERSON IN CHARGE I Name and Title TYPE OF FACILITY: FINDINGS: TN1qPF.CT0R: TFT Signature and Title RFPORT RF ..FTVFT) RV: I acknowledge receipt of this report: SIGNATURE: 02/96 P o.. Title: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information must bed completed prior to any scheduling. Date: 6 ° 7- 7-011 Engineer or Firm: �cld,� �>f�%¢ p; SL� Phone #: 00 <S 6Z 7-a 0ZY Person to Contact:--,7,—,- Z , ,Y V- ❑ New Construction Repair Program ❑ Addition Program Reason: PPDeeps (4--Peres ❑ Pump Test Road /Street: .19Z- 2 Town: ,AuAgji 66 %/..e, TaY Map #: Subdivision: Lot #: Owner: ❑ Project not within NYC Watershed, NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING YES N ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner reservoirs. Cl Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ ❑ roposed SSTS within 200 feet of a watercourse or a DEC wetland. El [� - Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department wili determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yes, to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professions and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: TIME: O� COMMENTS: Req.for field tesukly 4/16/2009 n.4 e•9.� •'— ...ya�A f� a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQUEST FOR FIELD TESTING All information must bed completed prior to any scheduling. Date: 6 ° 7- 7-011 Engineer or Firm: �cld,� �>f�%¢ p; SL� Phone #: 00 <S 6Z 7-a 0ZY Person to Contact:--,7,—,- Z , ,Y V- ❑ New Construction Repair Program ❑ Addition Program Reason: PPDeeps (4--Peres ❑ Pump Test Road /Street: .19Z- 2 Town: ,AuAgji 66 %/..e, TaY Map #: Subdivision: Lot #: Owner: ❑ Project not within NYC Watershed, NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING YES N ❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner reservoirs. Cl Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ ❑ roposed SSTS within 200 feet of a watercourse or a DEC wetland. El [� - Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department wili determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yes, to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the Design Professions and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: TIME: O� COMMENTS: Req.for field tesukly 4/16/2009 9 z qqq... ®;� Sy /fir > 1867 Church IS it !.'Clove Fxl- CARMEL iPo pp Jw n r� S � LAIfe ) !: Pon Camp Tacon! co Camplrig \ 8 � ;:Young Adulf .. a ' �.• �r / a }Reeves Conservation Corps � ��' '• Nelson Clarence F hn st ck cr�� 0 00 ,�., ova! h"dCr.• Catfish ! Pond 20 fn er ! O.y� 4.�9� • Po �pN 'O ® 1' .• is N Cornea $fit South 0 } ig h-- na" o Xom .' COW. o n H 11 Brook CHURCH p A vvUl2j? 1Y 10' ke 8 Cel %e PA .H i Y cw++�^N4 l� 22 PUTA AM V44EY _x� d JJJ I y�� •� gy P ® Li l� 7ti��: ki AV -�— - - - - - - -- —�� ! ATM- _ - -- --- - FU'Iin AWf GOUN TTY Dfl r, Dfvrsfon ;of fnliiro»menta! Heali Located at Subdivision z S"bd•'Erot' .e aMW V VJ.. , J owner /Address PLO Q 8uildirig iType ` tot Area c k VYtl Number of Bedrooms Design $low cZe /D Separate Sewerage, :system to 'consist •,of Ga To be ^constructed qy to hr Wnter Supply Public Supply From • > Privpfe Supply to 'De drilled .by Ccl k Address c, ti Other. Requirements E',�i6,`e�tc�� I,represent;that.t am1Nii6oIIYand3 camblete1v .resbonsibleaor.the'desian.ar IEALT'H " Ferniicr s•I I /.. y cr Town••��or ills e V., 1[J sc k Revision (may_ sous Approval ' Fill Section: Only ❑ P C `kH DNOtilication Required ..it ,a fir. yu _.,rav wrr5;va ur ra�a� afro uw��ar .niaiw place .in good :operating condition zany, ;part�of, -satd ,sewage disposal system duririy the per,ioc ance`•of the 'approval: of the.Certif,kate of Construction °rCornpliance of `the ­F, iginal system °oi will be locetedps sfiawn on theapproved. plan and that said well wili.,be in bccordance w County Department of; Health �, 47 .+ r *, A Date F� ' 1j, Address � r kPPROVEO FOR CONSTRUCTION �Thts app► val expires one,yeari om Lhe date"issued1 t.., } ,t x evocable for cause or may be amended •or +modified when considered necessary by the ommi s eq rtes a new- permit:' Approved for,.dt oral of domestic ry swag and /or nvaie w 11 ti late BY `. AAALL1,111i �ystem(s)'l 1) that' the `separate sewage disposal system itth the standards; rules an ,regu.,a ons o ,. e' u nam pliancy satisfactory toahe Commissions►, Of Healthwili >rs, heirs;or assigns by the builder, that said builder will wo (2.) years immediately,, following the 'date of',the issu- repairsahereto,'2j th8f =the drilled well described above. .- W. standards" ., _s and,; regu a"Tijons oof ",the ;Putnam nstruction;of the; building has been undertaken and is +r ' �Of Health �Afty- CltllDg '. alteration o f Construction ,supply only. s , �"". -' •Title u , �--' °' .' a t UTNAM COUNTY DEPARTMENT OF HEALTH // 9 Division of Environmental Health Services, Carmel, N. Y. 10512 CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM _ v-I-U a V4 Town or Village Located at �KLL�. -�e•r A Z OOwner .iCot w i Block •.:•'.�....•_•'.. ♦� �c�,�.�� Tax Map Lot # 'F .� 0 1 Subd. # Separate Sewerage System built by rl), l Address consisting of pal. Septic Tank and Other requirement; -7 i Water Supply: Public Supply From _2L Private Supply Drilled By - Address — �31 #JAry� Building Type �� �t � �V No, of Bedrooms. Date Permit Issued Has Erosion Control Been Completed? :1 TAX ARP iN rJ�,eO,e U,VTit ►y�r I certify that the systems) as listed serving the above premises were constructed essentially as shown on the plans of the e of which are attached), and in accordance with the standards, rules and•regulations, in accordance with the filed n, and the permit issued by thee. completed work (copies Putnam County Department Of Health. 1r Date r Certified by P.E. R.A. Address (7 l License No. Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to ae rs the correction of any unsanitary 1 conditions resulting from such usage. Approval of the separate sewers e available and the a Supply 9 system shall become null a d as soon as s public sanitary sewer becomes approval of the private water su I shall beco and void when a public wa e► su ply becomes available. Such approvals are subject to modification or change when, in the Judgment of th Comm Io of Health, such re ocati , modification or change is n Date_ BY Title �'U PUTNAM COUNTY DEPARTMENT OF HEALTH Permit # — D Division of Environmental Health Services, Carmel, N. Y. 0512• , CONSTRUCT• ION'- PERM IT- 'FOR7SEWAGE -DISPOSAL SYSTEM 1 A down OF village Located air' 1..._�_ t� J 6`C.0 f @ Tax Map- 91ock c-+� Lot, ! •� 7 Subdivision Subd. Lot # Renewal _ [3 Revision _❑ pp Owner /Address �` /T� �� �••' 5L Date of Previous Approval Building Type Aree�:1�� 13 Fill Section only � �� P. H. D. Notification Requires / Number of Bedrooms Design Flow G /P /D�1 Separate Sewerage System to consist of Gal. Septic Tank and To be constructed by �►' " Address Water Supply: Public Supply From Private Supply to be drilled by l� Address Other Requirements f• j 1 ��"' i U M I represent that 1 am wholly 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 there to and in accordance with the standards, rules an regu a ons o e u ham 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 during the period of two (2) year I mediately following the date of the issu- ance of the approval of the Certificate of, Construction Compliance of the original system or any repairs ther, o 2) that the drilled well described above,•! will be located as shown on he approved plan and that said well will be installed in accordance witLt., stand r S. r le d regu aTfrnS of the Putnam County Depart e t of H Ith. Date Signed P.E. R.A. Address v �-' License No. APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless construction f the building has been undertaken and Is revocable for cause or may be amended or modified when considered necessary by the missioner of Health. Any Cha eration of construction squires a new permit. approvor disposal of domest nit y sewage, and /or ri t r sylpply only. `� By CN—L Title 1 9-el " I A 5 xx ' 0 't :4r+ p m• µTi R I C O co, r • - - _:..._ _:. _ ___- _- - -- -- -�� a. o . . . Via• .. -', ,' �.: yto0 ; .• DEEP G'" - r ;. • .:t BELL. ..HgL,L O W... RDA D ,. on cq y, m m r (4 it a s x *yon y�3 'b 0. Co. © o co x -Z t p 2 y fn C o y) r 6N (n p w � j6l� 6 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF= :'ENVIRONMENTAL HEALTH SERVICES - COUNTY OFFICE BUILDING, CARPAL, N . -' -Y;.. ' .: 10512 _ _._ . ,...... . DESIGN -DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO, Owner �•�� Address [ Located at _(Street )f LL Lu>,X�T-�> Secs -Block Z Lot • ' • ?J l �-- (indicate nearer cross street) Municipality. lTjQAM AL u_= -.Watershed Aubs. o _ SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS 3 4 5 Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth measurements to be made from top of hole. o e Number CLOCK TIME PERCOLATION PERCOLATION. - No. .Start -Stop apse Time Min. Depth to water From Ground Surface Start Stop Inches Inches Water ve in Inches Soil Rate;;; Drop in Min.. /in drop' Inches 1 1 ?jp 'Z(cP 2 /��— 2. , 2S 3 2 Z� 5 7. Ap ! 3 4 5 Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth measurements to be made from top of hole. DEPTH G.L. 6•• 12" 18" 24" 3011 42" . 48" 54" 60" 66" 72'1 781 84" .O H_ TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN - :TEST HOLES HOLE NO. ) HOLE NO. HOLE N0. INDICATE LEVEL. AT WHICH GROUND WATER IS ENCOUNTERED 4 INDIC&TE__I V_EL- TO. WHICH_ WATERS LEVEL RISES AFTER. BEING ENCOUNTERED TESTS' MADE BY 'T/VI'L� Date _._.__._ _.__..�- • -- _ • -- _ !! Soil Rate Used Ict? 24 DESIGN 1in/l "Drop: S.D. Usable Area Provided No. of Bedrooms 3 Septic Tank Capacity OM Absorption Area Prided By L. F. x24 trench. Address THIS SPACE FOR USE BY HEALTH DEPARTP4ENT ONLY: Soil Rate Approved Sq. Ft /Cal. Checked by s iss Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONA -NTAL HEALTH SERVICES COUN'T'Y. OkFZCE - 3UT2iDING ;; :.,CA .. I'�'L;:..N;;,.Y; —:10512 .. . , .... ,....,.. DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner MARGE RY 5. 5AM VEL..S Address 245' EAST BO T/f _Cr .NEW YDRK W Located at ( Street etl ot(pu) L>ot _Sec. Z 2, Block Lot 4, 31 indicate nearer cross street) Municipality Q Y. Watershed ZM0k SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Elapse Depth to Water a er ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1-943 —(0413 30 2�- 26 *3/,a 1 7R,' 21 2 (D.- 11 -10-45 30 24 -- 3'0.44 -1'-4 -3 24- 4 5 02 19.45 -10:IS 30 24 243/4 40 3/4 3 tO =4.7- II ' 17 3(7 2$ 243/4 !�/4 40 4 5 1 2 3 4 5 Notes: 1) Tests 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. TEST PIT DATA REQUIRED TO BE SUBMITTED,WITH.APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOB N0. HOLE N0: _ ,_._._...__...- - H612`-NO:_ G. L. 6" 12" 18" 24" 30 36" 1 `t2" 48" 5411 60" 72 7811 /84" INDICATE I,31 VEL AT WHICH GROUNDWATER IS ENCOUNTERED _ ......INDICATE I BYLa aG�IF�� AD BEINi _.......- TESTS', . M _ ADE DESIGN Soil Rate UseC1 j �Min/l "Drop: S.D. Usable No. of Bedrrooms _Septic Tank Capacity 0000 Absorption. Area Provided By L. F. x24 i P 0 ENCOUNTERED J. .. , Date • -- -... _5 _ Area Provided ��S Gals. Type son l vi width trenc Other_ 01 Nam igna ure Addre ss 2 SEAL D D THIS SPAC FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by Date F o-'. A n, JUL 11 1984. * PUTNAM COUNTY DEPT. OF HEALTH TUKAI UrIN MCUIUAL LADUnM.lUR1 mu. ' LOCATIONS: P.O. Box 99 321 Kear� Street 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245•,3203 Yorktown Heights, N.Y. 10598. 201 BUTTONWOOD AVE.. PEEKSKILL. N.Y, 105615 737.8777 245'3203 C3 495 MAIN ST., MT. KISCO, N.Y, 10549 666.3335 ❑. STONE LEIGH AVE. (NEAR HOSPITAL),'CARMEL, N, Y. 10512 .278.9 LAB # Y10808 DATE TAKEN: 5/16/85 (2 P.M'.) DATE RECEIVED: S /16/85 (4:45) DATEREPORTED5 /18/85 JEFF MCDONALD sAMP1.E SOURCE. KITCHEN TAP: BELL 888 8th AVENUE HOLLOW RD., PUTNAM VALLEY, NEW YORK, NEW YORK 10019 REFERRED BY: L_ J COLLECTED BY :J. McDONALD LABORATORY REPORT mg /L 212- 157 -9715 ❑ ACIDITY .................................................... ❑ ALUMINUM .............:................... ....:...'...................... ❑ ALKALINITY ...................................... :...... ❑ ANTIMONY .......................... ..............................: gBACTERIA. TOTAL /mL ...... ...................... O ARSENIC ................. .. ....... ............................... 'lJ'BOO. 5 DAY .................................................... ... ❑ BARIUM ............:.......................... ............................... ❑ BROMIDE ............................... ... ❑ BERYLLIUM ❑ CARBON DIOXIDE, FREE .............................. ❑ BISMUTH ❑ CHLORIDE ................... ............................... ❑ BORON ............. ............................... ........................... ❑ CHLORINE .................................................... ❑ CADMIUM ................................... ...........:................... ❑ COD .:......................... ............................... ❑ CALCIUM .................................... ............................... ❑ COLOR ............ ❑ CHROMIUM (tot.) .............. ❑ CYANIDE ................... ............................... O CHROMIUM (hexavalent) ❑ DETERGENT, ANIONIC ... ..:............................ ❑ .COBALT ........: ........................... ............................... • O FLUORIDE ................... ............................... ❑ COPPER . .................................... ............................... O HARDNESS ............... .... .............................:. O COLD .........................:.............. ............................... ❑ h1PN COLIFORM COUNT/ 100 ml ...................... ❑ IRON ................. • • MFT COLIFORM COUNT/ 100 ml , ❑ LEAD ..... :. : :..... ❑ CONFIRMATORY TEST ... ............................... ❑ LITHIUM ..............:.. ................................................... ❑ NITROGEN, AMMONIA .................................. O MAGNESIUM ................................ ............................... O NITROGEN , -K °JEL-'DAHL ..:..:.:..::. .:.: 0-- MANGANESE ............................. ❑ NITROGEN, NITRATE ........ ........................... ❑ MERCURY .................................... ............................... ❑ NITROGEN, ORGANIC ... ............................... ❑ NICKEL ........................................ ............................... ❑ ODOR ....................... ............................... ❑ PALLADIUM ......................:. ❑ OIL & GREASE ............... ............................... ❑ POTASSIUM ............................................................... ❑ pH .......................:... ............................... ❑ RHODIUM I .................................... ............................... .. ............................... ❑ PHENOL ....................................................... ❑ SELENIUM .........................:.......... ............................... OPHOSPHATE (ortho) ....... ............................... ❑ SILICON ........:.....................:..... ............................... ❑ PHOSPHATE (condensed) ... ............................... ❑ SILVER .. ............................... .... ............................... ❑ PHOSPHATE (total) ....................................... ❑ SODIUM ....................... ............................... ............. ❑ SOLIDS, SETTLEABLE. m1 /L .......................... ❑ TIN ......... ............................... ............................... ❑ SOLIDS. SUSPENDED ... ............:.................. O ZINC ..................... ............................... ....................... ❑ SOLIDS. DISSOLVED ... ....:.......................... ❑ ..... ............................... .................. OSOLIDS. TOTAL ........... ............................... ❑ .................................................... .................:............. ❑ SOLIDS. VOLATILE ....... ............................... ❑ REMARKS:..................................... ............................... ❑ SPECIFIC CONDUCTANCE .............................. ❑ .................................................... ............................... ❑ SULFATE .......... :....................................... ❑ ........................:........................... ............................... ❑ SULFIDE .................... ............................... ❑ .................................................... ...........................L... ❑ SULFITE ................................................... ❑ .. ............................... .............. ............................. ... ❑ SURFACTANTS ............ ............................... ❑ .................................................... ............................... ❑ TURBIDIT`: ................ ............................... ❑ .............. ................. .........................._. ... _ .. _ ....... THESE RESULTS INDICATE THAT THE WATER Wru OF A SATISFACTORY SANITARY QUALITY W11EN THE SAMPLE WAS COLLECTED. THESE RESULTS INDICATE THAT THE WATER D MEET THE SATISFACTORY CHEMICAL QUALITY OF NEW YORK STATE ADMINISTRATIVE RULES & REGULATIONS, DRINKING WATER STANDARDS (PART 72) FOR THE PARAMETERS TESTED. ; 11. M.T (ASCP), DIRECTOR�G ALBERT .PADOVANI WELL COMPLETRM REPORT wil ` PUTNAM COUNTY DEPARTMENT OF HEALTH Division of EnvironfT»ntal Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by wellViller and submitted to County Health Department together with laboratory report of analysis of water sample indicating water is of.satisfactory bacterial quality before certificate of construction compliance is issued. DAY OVWELL COftAOC I'ON OWNER fro, E 6L,91 ADDRESS LOCATION OF WELL (No. d-Street (Teen) (Lot Numbod PROPOSED USE OF WELL DOMESTIC ❑ SUPPLY BUSINESS ❑ ESTABLISHMENT STRIAL ❑ INDUSTRIAL ❑ FARM D CONDITIONING ❑ TEST WELL OTHER D (Specify) DING EQUIP MENT ® ROTARY LENGTH (I of) COMPRESSED D AIR PERCUSSION DIAMETER (inches) WEIGHT PER FOOT �r CABLE D PERCUSSION ((�� L 'THREADED ❑ WELDED OTHER D (Specify) � UTED YES NO YES NO — CASINO DETAILS YIELD TEST ❑ BAILED [� HOURS ❑ PUMPED )�` COMPRESSED AIR G.P.M. YIELD (O.P.N.) WATER LifVEt MEASURE FROM LAND SURFACE —STATIC (Spec lfy loaf) DURING YIELD TEST [lost) Depth of Completed Well . i in foot below Land surfoce: / o SCREEN DETAILS MAKE LENGTH OPEN TO AQUIFER (loot) SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: Diameter of well including grovel path (inched): RAVEL SIZE (inches) ROM loaf) TO (Peep DEPTM FROM LAND SURFACE FORMATION DESCRIPTION Sketch orect two permanent location of wolf r0th distawee, to 41 1*"( iendmArka. FEET to FEET If yiold was tostod of difforont dopfhs during drilling, list below FEET GALLONS PER MINUTE DATE WFOLL COM LETE?,, # DATE OF REPORT IWEL ER ( _ natur Owner or Purchaser of Building Section Location - Street Lot Municipality Subdivision Name Building Type Subdv. Lot # GUARANTEE 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 guarantee to the owner, his success- ors, 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 made 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 determin- ation of the Director of the Division of Environmental Health Services - -- cif -- t - -Rut'na-rn County .1'e:pa tm ent-. of- Heal th-- as-.. tc�_ �ihetki :er._:.ox:_iiot_.th:e.:.fa.iL -. ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this ,�- y day of 19 �/ Signature 111144�� 11,14 Title rtlk, ) k Corporation Name Address THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. /Daly Division of Environmental Health Services, Putnam County Department of Health PUTNAM COUNTY DEPARTMENT OF HEALTH a DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of Located at /�"IL .14_1- D1_LDCJ (T ) 3Y ,W_ Section Block Lot Subdivision of Subdva 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 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 "_Arti.cle ..1-4_5...n.r. _, ... 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very trul Yours, l .. Signed Countersigned: G Own f Pr erty (VIE D R o A. , #� -r��� Address IV Telephone Address Town Telephone FIEsT T) CIM,C'K. L'CST. 0- COP INITIAL SITE, _ Yes No Comment ,Property lines or corn:rs found .. . Can estinia.tc hour location . . . . . . . . : . - V _ -- Will driveway need cut . . . . . . . . . . Must trees be r -mov-d -note: these Is deep hole representative of entire SDS area - Additional deep holes needed. . . . . . Sufficient SDS area available considering driveway cut,hou:;e location, separation ,• distances, etc . . . . . . . DEEP IIOLE DATA Depth: 7 hater elevation: . -. 0/ . Rock elevation: PO&Pi Soi3.3 descr_i pt•ion. S,a�r�y Date. FINIAL SITE I�•.1 SP) C`!-IG`: Insp. by: Hotse . Located vher.-e shown on approved plan '• . SDS located l ►hei e approved . . . . . . . :1ehgth of trench mca sured _ --- Width of trench aver : qe Slope of the line and trench. acceptable ' _ Room allowed for expansion trenches hTatural soil r_ot : stripped or SDS area iuuiecessa.rily graded _ 10 Ft. maintained ' from prop. line and 20 ft. from house Sepn'ra.tion of trench froi;i house, well -- e c . follows ' plan - Numiber of bedroo;r,s checks Stones, brush, • stw ~:ps, rubble, etc. greater than 15 ft. from nearest trench .. . 15 I't . of peripheral soil horizontally from trench ... Junction boxes properly set Could surface rtul off from driveway, roads, • ground surface, etc. chamiel near SDS area. . . . . . . . . . . Does l.ot• drair;aE;e app—car O.K. �i.n area of SDS -- FINAL MADING OF SITE ACCEl "1ABU br r11CV_% rTU _ C "C-,T - I OW/1 vr:� 0 t2� ` tL'�TITW CIH -.'CK S1fl. ,T (Meets Std. Remarks' es NO DOCU ,T,- NTS / ✓ �- P ®ssracY c�i� Eouse plans O.K. ! i3F- PR�e�j Design data sheet Peres presoaked? I-n. 30" pert test depth Const. results for 3 runs D. Hole log 0. K. t �f.R A-T Corporate Affidavit for oth p than individual luthorization for engineer I Letter from Water Supply .if applicable I If variance requested -such noted on plans & apps.: DETAILS , (if change -is proposed,) Existing contours shown ((show new - contours Slopes for driveway cuts, etc. shown lZ ter service line location Footing drain_, etc. location Top slope, bottom slope of fill Percolation tests and deep test pit location Sevtic tank size and conformance to std. 3 B.R. house minimum House setback shown Distribution box ftg. below frost All water within 50 ft. of PL shown -- Plan and profile SDS (: __._._..�.1 Tothgr -well`s aria -SL5 closer 200' shown .or reference made Property boundaries (metes and bounds - clearly sh SFPARATION DISTANCES SPECIFIED ON PLAN 10' to P. L. 201* to Foiuidation walls D0' to Nearest well )0' to stream, march, lalce, etc. (incl . expa.nsion L5' to Curtain drain !O' to water line (pits -20 :5' to storm drain 01 'to lar „e trcos .0' from 1,01111 ation to sopLic tank `)' to pipe from leader drain & • 1'oo Ling drain PfZMMrY �)©E.S QO "1grGa( `rf) K %L(op 100 C Po219T-e- 19 FF I'M Vt`I i I' i� %�1 I ® • , 0 1 S� I �S IO 1 t i I' i� %�1 I ® • , 0 1 S� I �S IO 1 t Gentlemen: I'lI;;,NA�I COUNTY f)I;):':1R'1MENT or IMALT11 • DIVISION OF ENVIRONWNTAL HEALTH SERVICES Date Re: Property of 'Irrh - VA I R. C011POC -4n C, pJ Located at IpsU, �UL V3 QD I'® , "�0W0 or- %� V0.` Section r-rL Block Lot 4.31- This letter is to authorize Patti McCo,�mack Smith -a duly licensed professional engineer X 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 corineur.iun wlch this marter and to supervise the construction of said system or systems in conformity with the provisions of Article 14S or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, Signed Z- Ow er tof Property Countersigned: Address P.E., jM&., # 047979 Route9, Garrison, NY 10524 Address - — -- - -- - (914) 424 -3848 .. Telephono Telephone