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HomeMy WebLinkAbout2694DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -1 -56 BOX 23 02694 Dc 66h of E Marc 'IC6 'ST R-t tiiCT tON R C Locate 4�t OF9 Own t Sewerage, System-, built by isti'ng ....... Septl&jank:3_' -�V q`, OEher '.requirements . 4, C_ Water upply:' ubli Supply, Fr6m.-4- v " ri a e . F-D i W4 A Jdress V C o"m Has Erosion Confro I' Been -"- !9s, IF -'s attached);�_,and,,n accordance -with the an d' 4� -'pate- U&J P & person ;occdpyh.ig premisesiserved ' by the aboveFsystem t:i,­,',P�cdnd1tiohs resulting ,.Jrom',such ,.'usage -" wYavailable and.the approval of water supply s 'change w'hen, `P V Ar —1 -A ""X, J" T 1601AAA LL EY" Town _ -Village 1B 16C IC D61 6nch A?' aV' ate; Permit I ss ofrthe completed work 4plldi, of W'fi ic6., grei-,' the 'P ajM+ Coqpl:y., Department trnfint 61.'Health: fi c7r," 07 R'*,,� License No Sa unsanitary, as soon ls ,,�qip,ublic.�4sanif�a,r,y-,��.,s,ew, er!,becomeS; 1­ j, li.j fi` are y,. becomes available a,b!e.,,, tlification or -change is necessary 1 UR4 r BACTERIA PER ML. (Agar.plate'courit at :350,C).:COLIFORMIGROUP (Mos6 probable No. /100ml.. LESS THAN : RD. ESS' TOTAL DETERGENTS - ppm NITRATES (as N) -. ppm 'IRON, TOTAL - ppm au Owner. or 1'a chiaer of building v Municipality A Building Constructed by Section I Location - Street p Building Type Block Lot GUARANTY OF SEPARATE SL'I9AGE 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 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 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 occupant of the building.. utilizing The undersi.aned further.agrees to accept as conclusive the determination of. the Director of the Division of Environmental 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' Dated this day' of rC' 19 7 Signature 64 a L" Title (if corporation, give name.and address THREE (3) COPIES ARE .REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUAP,4NTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of-Environmental Health-Services, Putnam County Department of Health Putnam County Department of Health ...Division of Environmental Sanitation AFFIDAVIT - CORPORATE a%TNER APPLICATION FQR;. PTf1T, ''.PL'fI,QDd�SL�iTED��O.�...,.. PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner.of Health In the matter of application for -_ ---- - - - - -- I, //—eu CZ 'I — — — -� — — — - e r Present that I am an officer or employee of the corporation and am authorized . to act for - ...,._- .. . . .. .. ... _. .. — ��_ / �r�s�ru.c�:vr, _ric, — — --- — --- — — .(name of corporation) having offices atC�` e/ _oac , —�— — — — — — — — — — — Whose officers are Presidenti_eC!_ 12 17c�ri7rprrr_ (Name and Address) -" Vice - President ArreZe w (AaiAe and Address) Secretary - U�� »����c cad _ _ _ (N -acme and Address) — Treasurer _ Ni�_ _Al, /,tc� _ � ^7j �Y�.� .X (Name and Address) — — — — — — and that I am and will be individually responsible for any or all acts of the corporation with respect to the approval requested and all sub- sequent acts relating thereto. Sworn to before me this �Z a d y Signed 216L - - I of A10 192 Title RALPH HERNANDEZ OTARY PUBLIC, State of New York No. 40- 1771735 Qualified in Westci+eser County Certifica!e fi! d .,!ith New York County Clerk Commission Expires Niarch 30, 1975 Corporate Seal R � WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 Division of Environmental Health Services �:- ..:�.,.:... ..,. >. ��r.-- -.-... ., .,. -« „4,- .,.�•:� >- .__. -. > �-.,, _.....,u.,..�,= ;,.`..;::..-.:�_ -- �,� _ -... ,._...,.CQUNT.Y OFFICE -BUILDING _ CARMEL�.. NEW YORK .I.s(�r ... I:�R C�.. ... .sa4rr...a -•� •..•0!...+r.. _.. R.: .. .Y;- wn n r1. .u:. . This report is to be completed by well driller 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. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NAME c -DA ADDRESS T LOCATION OF WELL (No. & Street) (Town) (Lot Number) PROPOSED USE OF WELL C� DOMESTIC SUPPLY BUSINESS ESTABLISHMENT INDUSTRIAL D FARM CONDITIONING D TEST WELL OTHER EQUIIPMENT ROTARY COMPRESSED AIR PERCUSSION CABLE D PERCUSSION E] ((SSpe ify) CASING DETAILS' LENGTH (feet) DIAMETER(Inches) WEIGHT PER FOOT / � THREADED ❑ WELDED S OE YES ❑ NO CASING YES NO YIELD T:ST ❑ BAILED a PUMPED HOURS COMPRESSED AIR G.P.M. YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE— STATIC(Specify leaf) ! DURING YIELD TEST feet) l Depth of Completed Well in feet below Land surfacer SCREEN MAKE LENGTH OPEN TO AQUIFER (too() DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: Diameter of well including gravel pack (Inches): GRAVEL SIZE (Inches) FROM (fee() TO (feel) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to of least two permanent landmarks. FEET to FEET G P aT- v r c / 1` xi CO I If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE ` 15741 2-5'd 4S DATE WELL COMPLETED DA T OF REPORT WELL DRILLER (Signature) a t a CONSTRUCTION PERMIT -FOR _ e d! aF?US E Located at �. Subdiviswn r Owner kit r[6F -P 1' „Building Type �A a1 o✓vtJry+✓Zl( I - Number :of Bedrooms Separate Sewerage; System rto consist o; To . be'.constructed r Water Supply µ. Public SuPP1Y, Private Supplj ' Address.;" r s* ry Other,: Requirements ' `:. r e i- .; cif �� •�• ♦ z:��.�ry.Ii 4.'`" X,'.. 1 represenfY that 1 ,am .wholly and ?complet .above ,_escrlbed will be constructed asst c :County ,. Departmeht of, .,Health, sand,th< f be submitted to •:fhe ,Department ?and place -in good operating,;condlLol!LRy; ( `.ance of the .appioval of the Certificate', r ;wall be locatetl as. show n on�:Yhe approved; Y +� UT NAM COUNTY DEPARTMENT ;OF ,yHEALTH ion of Envi onmental Health Services, CaKil di Y 10512 AGE: DISPOSAL SYSTEM `, � � ,. r/�. .1 . Vi (UA,Ri. VA1,L6Y. r Town ­ol Village Section Block Lot Job - �a ' t k #v., ? .gym v a t �, - a -r Address �LQ par0 k x � y.' '` Total Habitable Space � Square Feet Gal �Septici T :artk �Op �/� lineal _few ,x x r width ,trench s >`'� •.. Address - a - im , be drilled by i., � _ti t '7..' ST •=1.,�°:r�'�'� "7+�..' ,� i� q � _ £� n , $ .., _ � esponsible foreYhe desigrrand location of the proposed �sy'stem(sp °1) that.�theseparate_ sewage :disposal system in the ;approvedamendment there to" end;In accordance with the standards; rules an-_ regu'la Ions'o_' t e , u ri 4. completion thereof a Certificates of Construction Complian6 ,5atlsfactory tto tFie Commissioner'of HealEh will . Itten yt t.�;• h r • r " _ - guarantee;Swlll be.furmshed the owfner hisis�7ccessors heirs?or3assigns,by the,:bullder,'thatsaid ` buildei will of said sewage disposals systemti during_the period of.two (2) years Immediately, following the date of,the issu- Construction Compliance of` the longinal'system ` or any repaus- thereto 2) that the drilled,.well_ described- above and that said 17 well be` installed in�accordarl with the standards .�ru(es and regulatiorfs, of ,'the IPutnam` County Depart men t of Health° $ § 1 Dates "" �• , ,� � Signed r �' P/E'�_ j. Address �LONi /v - A'PPROvED FOR;CONSTRUCTION Thisapproval ;expires one year�from,the date issued unless construction of the..bullding: has been undertaken and Ib; ;revocable for' cause "or may be amehdedYor modifi @d?when consi Bred Necessary by: t _w stoner .of Hea'Ith Any change or alife tion`of construction requires anew permit Approved for isposal of domestic ni y ewage a % w, private', ter supply only Date °� By £ Title w` a1 �._.._� ... fin ... ,., , . M1 •,��, ... _._..... s :�:.� _. ,. .... ._:. -' PUTNAM� (,OUNTY - �DEFARTMENT " "`�1F HE'AtiTH " . DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date T • r, Re: Property of i i2, e, (= Fm A K) y� Located at C, A N.3" y c32i.�u I Z -t1'7I p Section . Block Lot Gentlemen: C This letter is to authorize Q �CNO�.r�S �JC fkQ (C -A YI I G`tLO a duly licensed professional engineer or registered architect (Indica e to apply for a Construction Permit for a separate sewerage system; to serve the above noted property in accordance with the standards, rules or regulations as promulgated by the Commissioner of the Putnam County 'Diepartri -,en , of Heca,ltil, 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 Article 145 or 147 Edueat-ion - L-aw;- the - Public• �-Hea-lt -li --fir, and-the- Putnam* - County- Sani =,w- -- tary Code. Countersigned: P: Z / 5 1 AA Address ' o 2r�e� a YCVr l� �-•�-- l- fsvlc� /iJ y �o >_ epnone elf¢ -739 -4-9 !1 L` Very truly ours Si , ned E g Owner o P erty OF 04 -Z4 IP �SSIONN% t .r Address e ep one 0 COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING CARMEL, N. Y. 10512 DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner L tZIC w f � ©FF MMQIO Address OL-o Caompos3o n ?a3D, C__Eysvri LC_, �•��. ! SG Located at (Street CAOOPJS �c uu PcooSec. . Block Lot indicate nearest cross street) MunicipalityTowu Of I`"U--()vpwtVA`t D' Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Elapse Depth to Water Water ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1 �'• 36 'z -3 I - 2 I :571 V02 z 3 4, o 3 x;04 3-2 3 4 D I . 4 x',19 14 25 32 3 4, S• 2 - 2 3;1 h - 3'30 4, �, 2--- 3 30 3 4.5' 2-- 4 3 5-(- 4 O C 30 3 � Z- 5 4'0�� 2 3 4 5 Notes: 1) Te'Rts to be repeated at same deptn 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. ; TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION ., DESCRIPTION. OF_SOILS.�ENCOUNTERED, lDT..TES'I- HOLES. DEPTH HOLE NO. L HOLE NO. '�. HOLE NO. OC�Oiowl v F+uF SAn.o 6 evtuh, to F.wjF vo G.L. i�,.�ee= a� s +� _ _ 71� act cF s +L �UYNE G n131,61 t- 9 (IV L0 S S0� r 6Y� uE 6" 1 1 12" 18" 24" 30" 36" 42" 48" 5411 60" 66" 721 78„ 8411 INDICATE LEVEL AT WHICH GROUND WATER IS : ENCOUNTERED ; ego G�vC.ovcv�='` - �- INDICATE LEVEL- TO WHICH WA'I'ER'-LEVa' RISES AFTER BEING:- ENCOUNTERED TESTS MADE BY Q I c- 44 Date �S &-P r, /S l9 ? 3 r7. DESIGN Soil Rate Used ( Min/1 "Drop: S.D. Usable Area Provided No. of Bedrooms 4 Septic Tank Capacity I Z. &I Absorption Area Provided By _.z `L. F. x24" luami; _L )ICH6 -L AS Jc+uiG�l tr��O Address Qt-p C Q p THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Raise Approved Sq. Ft /Gal. Checked by Gals . Type �c width trench. Other of Date Irf 0 S 'TI O � z n � • ,';1 lnQO Z r- ss =o "t ONE FAMILY r0 N __ r (i 9ti ee.Tfe .. 0 )o j6n> W J // 0 r .J m C. w / 7 -1 a �i Z in / T p r S t rt .p z ''NIS 1S TC C.ERTIFY THAT THE SE'MAGE 01SPOSAL SY6TEM L WAS ^_01JGTRUCTI:D A6 ilJ01C.ATc13 'Jti} 11415 PLAN An10 `r I { THAT Ti1E bYSTE.M W S 1l2SPECT'ED 3Y ME 4E;ZorkS IT Z -WAS COVE'RSC OVESi. THE <aYS'EMi 'NAB, Coi- Ic"r?oc -ED r cA IN ACCDR.aA�iCE WIN AL'.. T-AE i2'itES AmD i?F:,IJIATIDIJS OF nAE PLiTNAP/t C OU>1iY T�IEPAWTIAE1.1T_ OF \AEALT)A. ; ti7 p m JO R10 CA 1 i3 Q 1 6� 1p c f `- ^ p '1 Vas g-