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HomeMy WebLinkAbout2708DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -2 -18 BOX 23 ' 02708 LIM 02708 Re_�" -31!�06 Located i ,41" 'Xs O / :'v� wner /applicant Name 'J d Mallng Address PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 �� Engineer Must Provide I I -1 P.C.H.D. Permit N N�COMPLIANC FOR S AGE DISPOSAL SYSTEM � 'OWn OL e r i r 7L' Tax Map 23 /At,'* Lot �� J 4 He/�1 Formerly Subdivision Name � ` — Sabdv. Lot # ZIp S �% Date Permit Issued Separate Sewerage System built by 110 14104 elle- Address `+ Consisting of % C V O Gallon Septic Tank and S 6 y 4 o'-'- - Z-4 " W, � /'e, S water Supply: Public Supply From Address C , or: A"" Private Supply Drilled by A/ Y7 Address 15- ra a`�' d '409, Building Type Ali-5; dew d r Has Erosion Control Been Completed? Number of Bedrooms -3 Has Garbage Grinder Been Installed?? A/O I certify that the system(s) as listed serving the above premises were cons t me own on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and re stith the filed plan, and the permit issued by the Putnam County Department Of Health. ^ /l Oats Z� ?/ 'q/ 9 Certified by P.E. Y R.A. i Address License No. Any person occupying premises served by the above system(s) shall promptly to sill i4QAal necesu►y to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage syste ti, po nd void as soon as a pubt,: unitary sewer becomes available and the approval of the private water supply shall become null and void w ` ate► supply becomes available. Such approvals are sub)ect to modification or change when, In the Judgment of the Commissioner of Men such revocation, modification or change Is necessary. Date `iE' 6 G �C� . _ BY- _ Title �C -T• _. -..._<: wSo- Wn" tJ.Vrlrj rz11Vn 1 rrVA1 DEPARTMENT OF HEALTH :•......,.:e•.a- ..y. >._w.lis v..n Tir -�1 ..�S��- FC'S'.;F °. t. uy �...�T.; �Y �"'J':,�5'e�• -� PUTNAM COUNTY DEPARTMENT OF HEALTH__' , WIVRILUMNICI Office Use .Only - `-,.. _.- _ - WELL LOCATION STREET ADDRESS: W—N I Y TAX GRIO NUMBER /c/ e. S�� WELL OWNER ADDRESS: �3 ' g P81VATE ❑ PUBLIC USE OF WELLRE 1 - primary 2 - .secondary ENTIAL ❑ PUBLIC SUPPLY AIR /COND. /HEAT PUMP D ARAN NED ❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHTS"' gpm. 1N0. PEOPLE SERVED ===: / EST. OF DAILY USAGE .1 v n gal. REASON FOR DRILLING EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TESTIOBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL eft. DATE MEASURED DRILLING EQUIPMENT ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG WELL POINT ❑ CABLE PERCUSSION ❑OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH ft. MATERIALS: RSTEEL ❑ PLASTIC ❑ OTHER LENGTH .BELOW GRADE _—AA-ft. JOINTS: O WELDED i9THREADED ❑ OTHER DIAMETER " in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE BOTHER WEIGHT PER FOOT 1b./ft. DRIVE SHOE $DES ONO LINER: OYES &NO SCREEN DIAMETER (in) SL07 SIZE. LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST ❑ YES 'HOURS�M'� - - SECOND GRAVEL PACK O YES O NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH tL BOTTOM OEM ft. WELL YIELD TES? It detailed pumping METHOD: O PUMPED tests were done is in- COMPRESSED AIR , formation attached? O BAILED ❑ OTHER ❑ YES O NO 'WELL LOG 1f more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM suaFACE Water Bear- ing Well Dia- meter FORMATION DESCRIPTION CUE, ft. ft WELL OEM tt. DURATION hr. min. DRAWOOWN ft. YIELD gpm. Surface 3 7� WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? 0 YES O NO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY A GAL. WELL DRILLER NAME OA ACORES �J ``. Gr> rURE v /U .1 PUMP INFORMATION TYPE CAPACITY MAKER Z DEPTH MODEL VOLTAGE HP` LAB Yorktown Medical Laboratory, Inc. A : A Date Taken • 1- A -49b Time 321 Kear Street Date Rc , d: 11a7­& Time: Yorktown Heights, N. Y. 10598 Date Re .r Porte 3 9990 .._:,w. ,..�..: - �.,.,. - ..(9�'� P�+� �e`s� ,f`�'`=•= ' -. �.-� - .q�.,.. _w... rF. --�� :.;._� ,........� -.� -..tin I - a`.�:::. - ,�•`%i �- ��- :,.�,....,.,.. �.� . Director: Albert H. Padovani M. T. (ASCP) PO /Client # r Ref erred By: eL d o�� Sampling Site: Phone (I/Z) L REPORT ON THE QUALITY OF WATER INORGANICS mg L MICROBIOLOGICA 1 Om _ Alkalinity _ Chloride _ Copper Detergents, MBAS Hardness, Calcium Hardness, Total Iron _ Lead —.Manganese _ Mercury _ Nitrogen, Ammonia _ Nitrogen, Nitrate — Nitrogen, Nitrite _ Phosphate, Total Silver _ Standard Plate Count (CFU /1 mL) Membrane Filtration Method Total Coliform Fecal Coliform _ Fecal Streptococcus Most Probable Number Method _ Total Coliform Fecal Coliform _ Sodium Fecal Streptococcus Sulfate Sulfite. Zinc _ Total Coliform P A PH SI AL M S ELIANEOUS KEY FOR TERMINOLOGY _ Color�(Units) Conductance (ohms /c) _ Odor (TON) _ Turbidity (NTU) CFU = Colony Forming Units IT = < = Less Than GT = > = Greater Than NA = Not Applicable SA = See Attached TNTC = Too Numerous To Count REMARKS /COMMENTS or ab se (For Lab Use) SAMPLE TYPE: (Check One) ✓Potable _ Non- potable OUTGOING: (Check Each) HNO HC 13 H2SO4 VN OH ZnOAc _ Na2S203 _ Other: INCOMING: (Check Each) .....nom._ 4�C.::.... � .:..� . . GT 4 /LE 200C _ GT 200C _ pH LE 2 _ pH GE 12 Other: NYS ELAP #10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS) (WAS NOT) (NA) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO YORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE IME OF SAMPLE COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOL4COLLECTION. MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA DRINK- ING WATER CODES, FOR THE P ERS TESTED, AT THE TIME OF X %yj." 7/87 (Rvsd1 /90)RWE A e-r a ovani, Director PUTNAM COUNTY DEPARTMENT SIn�j CAF �o 9.11 17"60, 4 Owner or Purchaser of Buildi g Building Constructed by Location Street Municipality Building Type a3 Section Block Lot 1"061 - ;/ -'y g Subdivision Name 2 Subdivision Lot # GUARANTEE 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 with 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 iumediately following the date of approval of the � ,- - •r�:.— 'e —•iur. e' * br Y:e •s��raye -di��- 1 systu„- or'a . �f - c�ir_ ,r�.v 1„ • yL r , 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 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 system. Dated this 24 day of 19 Y-' Signature �jV e') Title General Contractor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk Corporation Name (if Corp.) f Address r/ Q �G�Y 1�% ....wtluCw�__u wonOYVU U1, '. 1 Otroei>Appliciist Nome, ` e h a ': E -' • Date df Pievboa revel Millbng. Addtreae ..Totvin of q� o Zip t.iepiesent toaCl am wholly.and completely responsitrle for the design rn .a above described will,be constructed as shown, !on the'approved amendment County ,, Department :of' Health, and that on completion thereof a "6iki be' submitted 4o the Department, and 'v: written guarantee will be fu_ir place, in goodropeiatinq condition. any. part o1 said sewage . disposal s, anCo. of ,the - approval, of'•tne Certificate, of, Construction. compliancai a will OetouteA'as sAoswn.on the aDP ►owed plan and .f hat said well will be',Irif County Depart ant of Health. T oats �...� Ik APPROVED FOR CONSTRUCTION Th approval expires Ro years fro revocable for cause or may be amend or modified•when c risldere nea requires,a ne ermi.• roved for disposal of dome c sanit se j Date By the separate ,sewage disposals stem ,the and regulations * of the Putnam y`to the Corhmissioner of Healthwill by the•builder, that said builder will Stately, following the'aate, pCthe Hsu- that the drilled well desc►iped' above' I and, regu 00ns : of.' the • Putnam- Syr ,.P E. R.A. 001st license No tcir -Pif the' building. has been undertaken vnd Is '.Any change or alteration of construction IW only. 1n1 Title � / #f/ DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT WELL LOCATION Street Address Town Village ity, Tax Grid Number ✓ls; .- ; ee- � � /� :23--r--e WELL OWNER Name ` dry Mailin Add res / ivate �3Sr�o s�/� asa/ %��/�r %�1�. O Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ® BUSINESS ® INDUSTRIAL Ir ® PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION 0 OTHER (specify, 0 INSTITUTIONAL ❑ STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED __ /EST. OF DAILY USAGE gal REASON FOR DRILLING UNEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY ®TEST OBSERVATION ®REPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE RILLED ®DRIVEN ®DUG El GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES A"'- NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Gn c 1/7c° Gv Lot No. Z WATER WELL CONTRACTOR: Name o frr! !4a• i Address: 3o iye,- %�9�• IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES A"�'.NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:/t/-,,�c,3 LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION P<N SEPARATE SHEET (date) ig t.ure s 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 provi ed by the Rutnam bounty Health Depart ent. Date of Issue: 19 Date of Expiration: 19 � ermit. ssuin f i,ial Permit is Non - Transferrable �� copy: H.D. Fil Yellow copy: Building Inspector 2/87 Pink Copy: Owner ___ Orange copy: Well Driller \ib w PU'1147M COUNT`_' DEPARTMENT OF HEALTH - DrTISICN OF ENVIRCNMENAL HEALTH SERVICES MIVIDUAL WATER SUPPLY & SUBSURFACE My�... -- DISPOSAL SYSTEMS ... . ... .. .r.P'•r�...C. ... .. .. a .l• r... yr pa.. .rw.ra ... --.. n .. .. .. eR!- i.:... t... x ♦..._-.. n —.. .... rr .v,y.. ��..r.r REVIEW SHEET - CCNSTRUCTICN PE —%14IT 00.1vo- of Cwner) (Street Lccaticn ) CCi'vTS YES I NO x x Ix I I I� t A.111 A I I I LF trendy provided op reuirad 100,1 kj C S 60 ft. Max. Parel.lei to M=ntOurs 100% e:%m- — 0� I I -Tel 11 x. u A-p AbobO sac. -X�N AEI ,e S FIA SYSTEM c k ba. rez 10 fV fi , tes as e -th gatlices Zo 100 vr. flood elev. 200 ft. reservoir, etc. Li 150 ft- trigall /gall . DATE REVIENED : BY: Lt.j DOCIRNE I'S Perm. Application Corporate Resoluticn Plans - Three sets Enginee_ -s Authorizaticn Design Data Sheet (,DDS) Deep Hole Log Consistent Perc Results Perc Hole Death House Plans - Two sets s/s SIJEDFTISION Perc (3) Fill ca Well permit; P S letter Varia ce Request �AL Legal Subdivision Subdivision Acproval Checked E;c- aoorcval SSDS Adj. Lots Checkad Wetland (Tcwn /DEC Pernit R & D) Data Cn DDS Plans & PeYnit Same REQUIRED DETAILS ON PT A-NL S SeWace Svsten Plan - (north arrow) Sevage Syst'-n Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or ren /Gallery; Pump. pit details Septic ank - ize, Detail Well Detail, Sery qp- idne.. if over. ... - c- onstj�uctior17Uctes --(;finder° "rate). Design Data: perc and deep results Two-Foot Contours Existing & Proposed Drive-way & Slopes Cut Footing Gat.; er.Curtain Drains (discharge OK) Perc Deep Holes Locat 0+"%f ANE' Represen runary and expansion Expansion Area; shown; gravity flow, suff . size If Pumved Pit & D Box Shown & Detailed House S No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Server - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveday, Large Trees,Top of fil. 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake Unc. ern 15' to Drains - Curtain, Leader, Footing 35'to catch basin, stornxirain,piped watercours: 10' to Water Line (pits -20') 50' inte- rmittent drainacte course Seotic Tanks 10' from Foundation; 50' to well I C 1 W-1 1 4- nr UjIUu'1 UA11�1) I .1 i11111'[r . i DIVISION OIL ENVIItCRHW- rAL REALM SUNICES a' tE IGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. :e%.r .. '•� �Yt�.�' ii%' G'ij �'��' � �j-� — �:.j�'-�' f°'- • x'.,'1 "'`"" •...•� ,dl.'i7. _� r. !: _ -. a .:-.- Located at . (Street) �// G Sec. Block 3 Lot (indicate nearest cross street) =icipaiity �y G.� �� Watershed SOIL PERCOLATION TEST DATA RDQUIRED TO BE SUBMI= WITH APPLICATIONS Date of Pre - Soaking Date of Percolation Test HOLE NLZMM CLOCK TIME , PERCOLATION PERCOLATION Run Elapse Depth to Water Frcm hater Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop- Inches Inches Inches 0 2-2- 7, 17 2 7' >v 3�y Y3 %/ 4 5 4 5 1 2 3 4 5 NOM: rev. 9/85 1. Tests to be. repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be submitted for review. 2. Depth masurements to be made from top of hole. TEST I'I'I' DNVA 'M SUIMITI'll) W1111 APPI,TCATION DESCRIPTION OF S011Z ENODUWMED IN 'IEST HOLES DEPTH HOLE NO. NO. HOLE NO. 21 31 41 51 71 81 .91 10, 12' 13' 14' 1NDICA-TE-*LEV'M'AT'-% k.RuuNC"A=j-- -1.13 utiii INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENIMUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used Min/1" Drop: S..D. Usable Area Provided No. of Bedrocms Septic Tank Capacity gals. Absorption Area Provided By L.F. x 24" width trench Other THIS SPACE MR USE BY HEALTH DEPAR24DN ONLY:, N W. 2489b . -`W Soil Rate Approved sq. ft/gal. Che&ftd-by Date DIVISION OF' HEALTH SERVICES' Owner -y r, A/ Ile -i Address 4.O 1,4/% acJ-. Located at (Street) Sec Block :5 — Lot (indicate nearest cross street) Municipality 7 4/4' 4y' Watershed' Date of Pre-Soaking Date of Percolation Test HOLE NUMM C= TIME PERCOLATION PEROOLATION, Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop Inches Inches Inches 75 V 2- 2 75W 4 5 2 4 5 1 2 3 5 NOTES: Te repeated at Same depth. until approximately equal so rates e,0 percolation test hole. All data to' be submitted ..'at each o 2. Deptimeasu "rements to be made from top of hole. rev. 9/85 4 5 2 4 5 1 2 3 5 NOTES: Te repeated at Same depth. until approximately equal so rates e,0 percolation test hole. All data to' be submitted ..'at each o 2. Deptimeasu "rements to be made from top of hole. rev. 9/85 T TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES r -per_ _sc _ -. - bJ�.ar �:cYt3Q1� • -i.rSo _x: -- fir•:`.- .:�Cxs -.. �r :�•ror -�.e s.�ll.'0I.:iG�.:lP�t1:V'-P,z� -� _ iav:�.:a ,..;s:z��tiu�- .zlllr�- •r'.,=.. ..._ . �<s.,.= ,.s-u:• r.e. aTb,..;••,+ G.L. ✓ ";< C� a / ✓%.' �' / 1' Jr 2' 3' 4° 5' 6° 71 8° 9' 10' 11° 12' 13' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED --- DEEP HOLE OBSERVATIONS MADE BY: L // �'�` DATE: " ✓ �� DESIGN - Soil Rate Used Min /1" Drop: S.D. Usable Area Provided'�"4 "' No. of Bedrooms -3 Septic Tank Capacity / -', gals. Absorption Area Provided By 3711c' L.F. x 24" width trench 1iC'M"m Nam �� �/� r " Signatur Address on THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: �Fo o 10 %� Soil Rate Approved sq.ft /gal. Checked by Type ✓ G 4 e rl' Date