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HomeMy WebLinkAbout2470DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 51. -1 -36 BOX 21 02470 - ` ON ' T , 16 1 ` I ' r fm t mfl Ir' �. i 02470 PUTNAM, COUNTY DEPA.RTMENT..,,OF= HFALTHr., .......,. ..: r .... a,... �.. ,A........ DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y.. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner 1_,PN�V,0 Address <'3 -0 eaei. :,v TABr /A" , Located at ( Street �� �uG �+a �.�� Be-c.. � Block �%- Lot /0,/ �_Ln ica e neares cross s ree Municipality o Z2 wA,.. A� :K. Watershed 6A vo fous SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION RM 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 P/ lai ZY 5 3 01 Notes: 1) TeAts to be repeated at same deptn until approximately 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. Ila 3 ice'% 12 4.3 17 Of /,;.v � /2 5 3 01 Notes: 1) TeAts to be repeated at same deptn until approximately 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. Addre s THIS SPACE FOR USE BY HEALTH Soil Rate Approved Date TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION ,...::....,,.:.:.... _�.. -. :...._ —:.—:DESCRIPTION-OF- SOILS- ENCOUNTERED`'IN'- 'TEST" HOLES::,:. -- DEPTH r HOLE NO. / HOLE NO. P HOLE N0. G.L. 1211 W cl y 1811 24" 3011 at 3611 4211 6g 4811 w 5411 ay 6011 6611 7211 K 7811 84" �1 I?NDICAT -E -LEA L- AT-- k=,CH....GROUND-WASER IS ENG&UUNTERFD INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY Date - ,- Soil Rate Used l.5 Min/1 " DESIGN Drop: S.D. Usable Area Provided No. of Bedrooms Ll Septic Tank Capacity ro Gals . Type Absorption Area Pro— d By 4/ L.F.x24" 3b- �-� -, width trench. Addre s THIS SPACE FOR USE BY HEALTH Soil Rate Approved Date L a77�c- . +,..- +. �i} �+'�•tr ..r —` +q y'1t�rr+-- �c -•�.». v�r^, ' -: sY S !}4x11 I i� 7 v I n: s, - I •~i�l..1. ,t PEEKSKILL MEDICAL LABORrATORY. 1879• Crompond Rd Barclay Plaza Bld g . A, Apt 1 . ; Peekskill, New York 10566 •r � } all , ' "��' �,� � PE, 7 -8777, { i, RESULTS OF EXAMINATION OF WATER DATE COLLECTED OWNER Pci i c ( DATE q . Yl u Yl » `5 RECEIVED CITY, VILLAGE, TOWN & /OR NAM$ OF SUPPLY l 7 OL DATE REPORTED SAMPLING POINT BACTERIA PER ML. (qqm Plate count at 3 J. 5 C). COLIFORM GRO P (Most Probable1No _ lOOmi) ' n a R N DETERGENT S -PPm S 3 X Yt d ' PPm f i NITRATES (as N) = ppm IRON, TOT AL- FLOURIDE (F) _ mg. PPm' t�'V t , t.; w t ' r {'! These reGU tS Indicate that the 'Water wue r 1��$ of a satisfactory sanitar u j Y 4 ality when the sample was !acted, A. H. PADOVANI; M. T. (ASCP ,1r4;; .moo Ajesi9oau si 96ueyo .io uoi ;eaippow 'uo!;eoonaa vans y;leaH ;o AMC aae slenoadde Lions 'alge!lene sewooeq Rlddns .te ;em o!Ignd a uaym PIOA sawooeq iames Aje;!ues ollqnd a se uOOS se p!OA pue linu awooaq Ileys we;sl ) Cae;luesun Cue ;o uOlioaaioo ay; ainoes o; Ajessaau eq Rew se u0n :)e Lions 'Ie ON asuao!-I LilleeH ;o ;uaw;.iedea +C;unoo. weu;nd a�q. �a�uo umoys e A aae, Li31ym ;o saldoo) )Isom pa;eldwoo ay; }o sueld ay; AS elea 6pn( ay; u! 'uaym 96ueyo Ao uO!leo!ppOuj o; ;oa(gns ! ddns Jejem a;eAlid ay; to lenoidde ay; pue algel!ene IenoaddV '96esn Lions woa; 6ulllnsei suOl3!Puo3 Sys qe ay; +Cq PaAaas saslwaid 6ulRdn000 uOSAd +Cuv . ssaapPV e ;ea epue ;s ay; 4 ;!m aouepa000e u! pue '(Payoe; ;e ay; 6u!Ajas pa ;s!1 se (s)we;s+Cs ay; ;eLil +C;! ;Jao I ipa;aldwoj u899 10A3uoD uO!sOA3 SeH panss 1 ilwaad a ;eo swooapag ;o 'oN � 9dA1- 6u!pl!ng ------------ � S ss9jpPV Liouei;; 41pim X 109=1 leau!I t� SsaaPP P 1 1 -� qOI 30 ,•o A13 PalliA(ff+CiddnS a;eA!Jd — woad AIddnS o!lgn"d :AlddnS aa;eM s;uewaa!nbe.i Jay 40 )juel 011daS 'leE)— }0 6ul;s!SuO3 '0 7 �Cq 11inq wa;sRS 96ejameS a;eaedaS aaumO �U a3e3ol un �iool9 Q� ? 7 ✓ r Z' C�VLJ Yr. 06elliA Jo umol W31SAS 1bfSOdSla.39VM3S HOJ 33NV11dWO3 NOinnelSNOo :10 31` 31411x33 ___ Z.190.•s .l '/l( H_1P WUonnu3 J.9 uois/nrp HH111V3H-H 10 Im3Wiavag0 A,H,I mw H/dVALnd[ PHJTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N. Y. 10512 CONSTRUCTION PERMOT FOR SEWAGE DISPOSAL SYSTEM �� �'i;l+ -ld�r, �1`�L 4 � >'y' Located at L �" *='L G �;,zl 441-, Town or Village A�lA � l T_ , / Subdivision �" id�/Ji ITl Section ` % Block ;7 Owner /QrhfG ,�� %V'!V' +1� Lot a✓ �• -99-- 4V 21Z `j` Address -s' Job y � E'k�A�S Building Type) % /��/i /l�j Lot Area �L�`►St�. -/ Number Of Bedrooms Total Habitable space d119'il Square Feet Separate Sewerage System to consist of e °0 al S ti s7 i / U F ep c Tank - lineal feet X width trench .. - To be constructed by "f�`:s�' Address �i {:.� f G,f ` •• �'l f•" /Wt S�= .:,� / �• 40, Water Supply: Public Supply From � f Private Supply to be drilled by Address Other Requirementsh� /�!f�G I represent that I am wholly and completely responsible for above described will be constructed as shown on the appr County Department of Health, and that on completi be •Submitted to the Department, and a written gu Place in good operating condition any part of sa ance of the approval of the Certificate of Constr will be located as shown on the approved plan and t w County Department of Health. Date Address " "" - APPROVED FOR CONSTRUCTION: This approval ex 1 i revocable for cause or may be amended or modified when requires a new permit. A p Ove or di osal of domestic /•_ s++ Date— By of the proposed system(s); 1) that the separate sewage disposal system and in accordance with the standards, rules an regu a ions o e u nam Construction Compliance" satisfactory to the Commissioner of Healthwill caner, his successors, heirs or assigns by the builder, that said builder will [ . the period of two (2) years immediately following the date of the issu- I system or any repairs t ereto; 2) that the drilled well described above Frdance with a Stan ard�fs, rule ;._and tegu a�irons- »- of- ••:ths, F?utr"aZY!' __.� � J P.E. � R.A. License No. LIP te� issued unless construction of the building has been undertaken and is the Commission of Health. Any change or alteration of construction e w su I • SIT WT MAILING ADDRESS T U rf-tk UA U 0, I -IZ- Y P lei NI , i® S -7 f�reA",A -,mss V NY.� ©�a` PHONE PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE ?.-( ei TYPE FACILITY �Lc� PROPOSED ALLER ti PHONE Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. 11 C44 T 1604 Proposal app ov K Proposal Disapproved Inspector's Signature & bate 'roposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above .proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE ' TITLE DATE FUSS: Mite (PCHD); YeUcw (fin ED; Pink (Appl wt) b WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEAL' 3/71 Division of Environmental Health Services COUNTY OFFICE BUILDING CARMEL, NEW,YO.F This report.is to„be:..cgmpleted- by well, driller,-aiidsutimltY> I f3'Countya}�"ea6. Department together With laboratory report of analysis of water sample indicating Water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT ROUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER N6,ME ADDRESS - LOCATION OF WELL (No. B Street) (Town) (Lot Number) Pl30POSED USE OF WELL DOMESTIC E] ESTABLISHMENT ❑ FARM ❑TEST WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING El OTHER DRILLING EQUIPRAEWT AIR CABLE El ROTARY AIR PERCUSSION ❑PERCUSSION 1:1 OTHER. (Specify) CASIRI0 DETAILS LENGTH treat) ��j DIAMETER (inches) rp it WEkiHT PER FOOT © THREADED ❑ WELDED I E S O YES NO W CTA$1 TED? YES NO YIELD TEST ❑BAILED ❑ PUMPED © COMPRESSED AIR HOURS G.P.M. YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE— STATIC(Spdc)fy feet) DURING YIELD TEST fleet) Depth of Completed Well in feet below Land surface: SCREEN MAKE LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: =Diiameter olf including nches): GR AVEL SIZE (inches) FROM (feet) TO (feet) DEPTH FROM LAND SURFACE FEET to FEET FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. () G If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL CO `P TED DATE OF REPORT WELL LER ( �natu ) 'a /�'!�' ���✓'ti`�✓�l% Dd•��iV� vc7� ��T"/L'•�'-I �i¢GGFIl'.� �,_.._... Owner or urc asF er of Building Municipality T Building Constructed by Ou.4, . 4 6. 11 bu.) 4,40 Location - Street Building Type Block Lot GUARANTY 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 guaranty to the owner, his succes- sors, 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 de- termination of the Director of the Division of Environmental, Health„ Se.r.- - v...c_e.s- ..of:_ the. -Datriam- .4oun- y.- Deparrtm&nt -' 6f-- He!alt-h -as- to- -whether -o,r,'not" the"' - failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the tem. Dated this day of z2c 19 746� Signature Title ,eCa r- If corporation, give name and address) !Ice .�% •- %��5`,�% 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. Division of Environmental Health Services, Putnam County Department of Health 0 Gentlemen: PUTNAM COUNTY DEPARTMENT OF HEALTH DI VT- SION OF N 'T'i i7hTt�iEI�1TA "'F 1 LT}'f"S"EFtiTICES Re: Property of Date Located atstI ii. ni i.�s A�cgp 1JWI✓ I Ax 111 -c- Vin . �`- Block _ Lot . This letter is to authorize TAMIL°u J. ®ER 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 nece$sary papers on my behalf in connection with this matter.and to.supervise the construction of said system or systems.in conformity with the provisions of Article 145 or 1.47; Education. Law the Public Health Law, and the _- Putnam. County. Sani- tary Code. Very truly yours, Signed��('' r.ts` Owner of, operty Cou tersigned: 0 J 71, . ' C`} Address ,, =✓ � elephone 6rriCs li P t p a - . ."_ 245-2645 �� e'er }. 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