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HomeMy WebLinkAbout2753DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62A-16 BOX 23 i ♦ �� r �` , , . ' r IL . =1T *d NN INN, . in 02753 PUTNAM CO(TNTY_DEPARTMENT OFHEALTH Division'.of Environmental Health Se vicex, Carmel, N Y 10512 S a ' Engineer M6st Provide Z5: PC:H D: Permit N= " L'EP'rl if :sTE OF- �`(.iVC7Rila."r►(1N C0;►T � IANGF FOR SEWAGE DISPOSAL, SYSTEM • � Located atr Taa`Map Block Lot : 3. l ill wA �f �/ Owns Zappllcadt Name a.- M . ^ ` � Formerly Sabdivislon Name � � Sabdv Lot q MaWn(; Address - Date:Penmit.Iasaed :.'. 7 Separate;Sewerage System ballt by�' ' V F-%�� Address AM '. 1 Coneletlog Gallon Septtc Tank and - :. Water,Supply: • . ` PdbOc Supply Ftom s or Private Sapply, DrWed ;tiy } $allding,Type �i��1 UGN.� Has Erosion Control Been Completed? � ` � f Number: of Bedrooms Has Gar a Grinder Been lne +~OF NE Other Regalrementa �� f L I certify thpt the system(s) as listed serving the above,rpremises_ were cons ct senfial.Y ae:e}i on a plena,of the compl ted work;( copies , of 'which are at ached) ;and.in: accordance with the standards rules and.req laf , +iri ac rice' h ' led,`plari, and the, ;mit"isaued by the Putnam County q r ntf Health /1 Date Cert tied by P E, v Ii,A j Addreu • } Llcehse No Any person occupying premises served by'the above systems) shall promptly take iA n �fh a to tecun the torrectloh ,of any\ unsanitary (1p conditions resulting from, wch, usage- Approval of the_ separate sevveragesystsm. typ d t s soo�,at a pub:' YnlUry awa becomes avallable;_snd the' approJel of the: private .caster supply shall become null and ;void wh ply becomes available {3uch approvals are subject 'to .mbdiflcat {on,or chan4e' when, in the,)udgmeiit- of the >Comm {ssfoaer of Nea lori.'iriodlfieation or'ehanga Istnecesssryi DatrG- ,y`---_1 i/—'� Title e YK.000914 LAB . # . Yorkt own Medical : Lab®rat®ry9 Ins earStrcet Collection Station Used: 321 HC Yorktown Hei&s, N. Y. 10598. Carmel _ Peekskill _ .. .::; : • '' (h14) 245 -3203 ` _ Director: Albert H. Padovani M T. (ASCP) Dat a Taken: Date Received: Date.Reported:_ Collected B Referred By:. =3 Sample Source: L„ LABORATORY REPORT ON BACTERIOLOGICAL QUALITY.OF WATER GENERAL BACTERIA Standard Plate (Agar plate MEMBR NE FILTRATION Total Coliform Fecal Coliform Count per 1.0 ml 2.35 °C) TECHNIQUE (MFT) per 100 ml_ ner.100'ml Fecal Streptococcus per 100 ml MOST PROBABLE NUMBFR :TECHNIQUE (MPN) Total Coliform: MPN Index ner 100 ml F'ec'al Coliform: MPN Index per '100 ml OTHER ANALYSES THESE RESULTS INDICATE THAT THE WATER I SAMPLF�(WAS) (!WAS NOT) (NOT APPLICABLE) OF A SATISFACTORY' SANITARY QUALITY ACCORDINdd TO TIL NEW YORK STATE DRINKING WATER STANDARDS, FOR THE. PARAMETERS TESTED,, AT THE TIME OF COLLECTION. r t (-, o Albert H. Padovani, M.T. (ASCP), Director LEGEND RDS = Recommend Disinfect- ing Water Source < = less than TNTC = Too Numerous Too Count K. T.TL'T T !lllMOT VTTnHT DVDl1DT Y� ITLLY VVaaa L —w— aWi Va \i -� DEPARTMENT OF HEALTH Division. Of Environmental Health Services ,.. .... .�yrl•.''_��. O�„ o. -, >�_ _.re me.u.o- ..,.....,... _ .. ..:...- = « z: ar> }::.... ;..'.: . - •... -,- . •-.... �: r.-. .a:.,.- :...•, PUTNAM COUNTY DEPARTMENT OF HEALTH Off ice' Use Only :,.: _,.:,.,.._— ..............::� :-::;;, .,...:r.....; . �. .... .,. WELL LOCATION STREET AOORESS:� IAUICIIY TAX'GR10 NUMBER:- ` WELL OWNER NAME: ADDRESS: 70 2 PRIVATE PUBLIC USE OF WELL 1 - primary 2 - secondary ESIOENTIAL ❑ PUBLIC SUPPLY.. O AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS O FARM 0 TEST /OBSERVATION O OTHER (specify) p INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED ---- -7 EST. OF DAILY USAGE' —" gal. REASON FOR DRILLING 9NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY. O TEST /OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA O WELL DEPTH ft. �/3TE STATIC WATER LEV MEASURED DRILLING EQUIPMENT ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT O CABLE PERCUSSION O.OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING. OPEN HOLE'IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH _ ft- MATERIALS: f9 STEEL O PLASTIC O OTHER LENGTH.BELOW GRADE �_ ft. JOINTS: . 0 WELDED. THREADED ❑ OTHER DIAMETER. in. SEAL: O CEMENT GROUT O BENTONITE WTHER WEIGHT PER FOOT f'� 1b./ft DRIVE SHOE_)25tES p NO LINER: ❑ YES J.NO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? DETAILS FIRST o YES ❑ No GRAVEL PACK ❑ YES O NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH tL BOTTOM DEPTH, It. WELL YIELD TEST If detailed pumping METHOD: O PUMPED tests were done is in- COMPRESSED AIR , formation attached? O BAILED C3 OTHER -OYES - O NO WELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE water Pear- ing well Dia- meter In FORMATION DESCRIPTION caoE, ft. IL WELL DEPTH ft. DURATION hr, min. DRAWOOWN (t, YIELD gpm. Surface WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES ❑ NO ANALYSIS ATTACHED? O YES ❑ NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE qqJ CAPACITY S MAKER /•1Q Y DEPTH °� MOOEL 1 e VOLTAGE�Q�HP WELL OR ER NAME OAT p ADORE .C�3 StGtbtT11RE o " i 0 s'7 I r4 GUARA1q= 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 immediately following the date of approval of the "Certificate of Construction Compliance" for the se;%* rlispo a system, -ter any _ - y j. ,.�., ��, _ tail - rep�, rS ^�:d, :,J' _mc; :tG .�4iCliJVStfie!,�'�j`t c::2E. c u.c La11uC� to: operate_-properly...:is C!aused_ 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 �� day of K.1C> 19 al Contractor (Owner) - Signature Signature Title Corporation Name (if Corp.) Corporation Name (if Corp.) KWess Address rev. 9/85 mk PurNAM COUNTY DEPARU1E Tr OF HEALTH - DIVISION OF ENVIROMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS FT7Rr INSPECTION - -- - SY INSP.~BY: (Name of er) (Street Location) INITIAL SI INSPECTION YES NO COMKRM Wetlands on/or proximate to property .............. Property lines or corners found ................... Can estimate house location ....................... Will driveway need cut ............................ Must trees be removed - note these ................ Deep holes representative of entire SDS area...... Additional deep holes needed..... ........ .... Sufficient SDS area available considering driveway cut, house location, separation distances,etc... Adjacent wells/ septics ............................ u.n. - ixcN nU.tC G.W.- Groundwater D.H. 1 Lot D.H. 2 Lot D.H. 3 Lot Depth to G.W. Depth to G. W. Depth to G. W. Depth to rock Depth to rock Depth to rock Soil Descrip 0 ft.. 3 ft. 6 ft. 9 ft. .boil vescri 0 ft. 3 ft. 6 ft. 9 ft. 12 ft.. Soil Descri 0 ft. 3 ft. 6 f t. 3�, 9 ft. DATE: FINAL SITE INSPECTION INSP.BY: YES NO COMMENTS House SSDS located per approved plan.... .�- � �^ l C dU-- Length of trench measured �.. Width of trench average Slope of tile line and trench acceptable......... Al �► s Room allowed for expansion trenches .............. Over 100 ft. from watercourse .................... Natural soil not stripped or SDS area unnecessarly graded ............................ 10 ft, maintained from property line and 20 ft. from house... ... ... ..... . .... Distance well to SSDS (ft.) l,�1�.�j .. n� "l ...�.�::.... Number of bedrooms checks ........................ � (, C • o hot Stones, brush, stumps, rubble, etc., greater than 15 ft. from nearest trench... o ............ �-� 15 ft. of peripheral soil horizontally from trench ..... ........................ -2f Boxes properly set ............................... Could surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... - e�✓' e I FINAL GRADNG OF SITE ACCEPTABLE .................. V 'K.;. T -u r!. OIV PERMIT FOR Located at _ PUTNAM COUNTY DEPARTMENT . OF HEALTH Permit w Division of Environmental Health Services, Carmel, N. Y. 1051 EM Tax Map _ Building Type Lot Area � • Number of Bedrooms Design Flow c /P /, C) Sepa rate, Sewerage System t consist of 0Od U Gal. Septic Tank To be constructed by %h Water Supply: Public Supply From �yy/G Private Supply to be drilled by � 4C _e Other Requirements I represent that 1 am wholly and completely responsible for the design,apd t above described will be constructed as shown on the approved amendment` er County Department of Health, and that on completion thereof a "Cer icat be submitted to, the Department, and a written guarantee.will be f ishe place in good. "operating condition any part of said sewage dispose sy`st ance of the approval. of the Certificate of 'Construction Complianc of will be located as shown on the approved plan and that said well will be n County Department of - Heeaaltth. Date` ` Signed ^ , 1, Address APPROVED „FOR CONSTRUCTION: This approval expires one ye�from revocable for cause or may be amended or modified when considerecQitecessar requires a new permit. QQA/r�pproved for disposal of domestic sanita s agE Date' 23 JS6 By Rev. 9 -81 Oats Of Previous Fill Section only Revision /�. ❑ X rVT —v P.C. H. D. Notification Required and 3 5 /( J Address F NEW t e p ystem(s); 1) that the separate sewage .disposal system �o i ®�cFt� hce h. the standards, rules and regulations of the u nam Q onstru2tkap mpl nce” satisfactory to the Commissioner of Healthwill .8.0 er, his rs; airs or assigns by the builder, that said builder will curing period of wo ) years immediately following thedate of the issu- )rig 1 or r rs thereto; 2) that the drilled well described above in a wit t s ndards, rules and regula ions of the Putnam ®. 17 P.E. R.A. License No. 1tq�,jssued nstruction of the building has been undertaken and is ne► of Health. Any change or alteration of construction id a water supply only. y� �&` Title • (TIr- .�. ..- _- _r.c+. n ._.... _ 1 _. .- - .. ........ ... ...� ... � ...... 4. a._kc .� -rte... ..... - a.. .v .-.. ...,. ..., .0 ..... ... .. ....e _ •f PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ;N.;­ Y DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM - FILE NO. Owner t4f.kH0.4V)4BMbY Address St1V$C-(HtLL-R0AAS Located at (Street I Sec. 5:1- Block .3 —Lot 3,11 —LOT 6d.icate nearest cross street) Municipality SOIL PERCOLATION TEST DATA Watershed TO BE SUBMITTED WITH A CATIONS Hole Number CLOCK-TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Water.Levei No. Time From Ground Surface in Inches Soil Rate Start-Stop Min. Start 'Stop Drop in Min./in drop Inches. Inches Inches 24 "1 Z 01? 2 Vt 3 16. 0 2 1:30 00 3o Zl Z4 5 3 ti No 23 Z'/z. 4 3 4: 40 30 Z5 '14 3 10.0 14..... .. ._..:.. 6A I -14 "- 3 8:15- OP.40 ZS 12 f0-0 5 2 1 Notes: 1) Te'�ts 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 measurements to be made from top of hole. G.L: 6" 12" 18" 24" TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES 30 36" 42" 1 48" wy- to MEOW 54 If 10 4 SILT5 S7t..'r 60" 66" 72" 1 78" 8411 f INDICATE .LEVEL AT WHICH GROUND WATER IS ENCOUNTERED. _I IC TF I�E`TEI� .TOs: �rl� �_ CH WATER : R Sys . FTER "BEING..ENGOUNTERM.k7��� TESIS...yiADE .Y �T'Y'►Ft't .. c` v.:'i.� T DESIGN. Soil Rate Used Min/l "Drop: S. D. Usable Area Provided _J� 0-0c) j No. of Bedrooms 3 Septic Tank Capacity . t0F EEgly� P'C U9 . Absorption Area Provided By 315 L.F. x24" en y Name Amuamr Signature � a Address g s PCyWAk-,1 *Vs . S EA L A! `C -VDt0 d Alai (M( V., THIS SPACE FOR USE BY HEALTH DEPART14MT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by �'0 1 r! t Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property o Located at (T) Section Block Lot Subdivision of ':c►12+ ✓ .���wN Subdv. Lot # Filed Map # Z %� Date Gentlemen: This letter is to authorize a duly licensed professional engineer V 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 .conf- ormity v:it -fin..the, -provilsi-p-ns. of Article. 14.5 ox _.-. -. c. ..... .,.. -..�.. �,.. .... -. -. .. .�- ... a ...... - .....y __ _ .: - .- �.- ......... -.. -.� -- �...... .._-. o.. ......... ....�.�.- ... _.... .__ .... • ...... -_.. .�. _.. - .... --- -•-.. -.nom. 147, Educ tary Code., !1 Countersig# P.E , R.A. #_ Public Health Law, and the Putnam County Sani- S/ OF NEW y7o DE44 • 1� /I S bee .MAAJ Av W.. Address 14 w Q W tA)9;-AA Telephone Very truly yours, Signed kal(t `l" X&OA/ �< Owner f ro ert P Y Address Town Terleptione r. , . �•, � �{• : •ic' ICI ' • .I .' / •' • �' , . 1' • f 'ICI' ' � .1 ,' �1' M - . -.° v �. - RE�IIEW SHEET CONS'I'RU�°�.`TQN- P3;�T. u DATE ^RENT -7 BY (Name of Owner) (Street Location) DOCUMENTS- Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets If PWS - Letter Variance Request RDQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flaw Fill Profile & Dimensions.- Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area �«nyinhl If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 2001 in D.L.O.D, 150' pits 1001 to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' frcan Foundation 50' to Well 15' Well to PL COAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same ENGINEER TO PROVIDE PERMIT # J. PUTNAM COUNTY DEPARTMENT OF HEALTH..' ON cERr FICaToF o LI- I�l(�E. t . ']�- 1 Division of Environmental. H In Services el ,N. rY `10512 PERMIT CONS UCTION PERMIT FOR SEWAGE; DISPOSAL SYSTEM Al k I hu 1 Town) or illage _A Located at �-- �?`,"j� t � Ci �+` "��-?1C-i" - i ax' rvlep Subdivision � � � S41A Lot N 1'.` Renewal Revision Ownei /Address`' •• Date Of Previous App royal :�: l3uiltling Type n Fill Section On Act-- LOt Are�ay!' ( el�% ly (] Number of Bedrooms Design. Flow G/P /D L'^ F•C. H D Notification Required �. /Jit s Separate:r5ewerage.> System to' COnsist o(, Gal. Septic Tank and'.. r� ' 70' be constructed by1 ► '{� • Address Water Supply; Public Supply From e Private Supply to tie, drilled.: by ` - Address Ottier' Requirements (.represent that I 4m -wholly and completely responsible for the design and location the proposed zystem(s); 1) that the separate sewage disposal system above described; will be constructed is shown on the approved amendment there to and in accordance with the standards . ruleran regulations of e .0 nam County '. Department of Heatth;' "and that on completion thereof a Ce►t�t�cate' of Construction, Compliance satisfactory�to the-Commissloner of,lieattnwill be isub'uritted to the Departments' and .a­:written guarantee;`will be •furnished' the owner, his successor>ti heirs of assigns;tiy tlie'builder; that said •builder will place ,i� good operating', condition any •part of said sewage disDOSaI system, during;fhe period of two,(2),:yearslmniediately following ttiedate .oi the iszu- ance of the approval.. of the Certificate of.. Construction, Compliance of the or 'i al. system or. any repsirs,thereto••2 t the drilled well' described above will be loWted.as shown. on the approved plan and that said well will.be install 5cc Yda' fie`,st Bards, ; , eva 'd `rey Boni "ot the •Putnam County Departure of Health: JQV Date Signed`,: p E. R:A. Address 3 ' License N• APPRO,V.ED FOR CONSTRUCTION. This approval'expires: one year from the date issued unless eon ructio�'.of the building.•has been undertaken and is revocable,for cause or-may 'be'arriended or.'moditied when considered` necessary by the' ommissioner of Health. Any change 6, r alteration of construction requires a';new permit. Approved for disposal: of :domestic sari ary sewages a d /or,5 rvat ]water iupRly; only. Date I © I�QIL gy CU: 9 ^ Title ORE - Rev. 6/85 .. ci PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date u G 198 Re: Property of Located at -- 4)u_ T (T) L(f� . Section_Block Lot Subdivision of riJ Subdve Lot # Filed Map i ��. 0 Date Gentlemen: This letter is to authorize a duly licensed professional engineer `or,registered archi,ect (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 Article 145 or 147, Education Law, 'the Public Health Law, and the Putnam County Sani- tary Code. Countersi /, r---TD R o A Address j Al I/ Very truly yours, Telephone �".�PIN t_ —Owner —.: rr, , , s A - � Telephone PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .`i71�'..; DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner r�?iC M_eGRS Address' Located at (Street 'i 11 ��t iec. Block Lot �indicate cross s ree Municipality K LLE Watershed D� � SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION4 PERCOLATION xun No. Start -Stop Elapse Time Min. Depth to Water From Ground Surface Start Stop Inches Inches a er Level in'Inches Drop in Inches Soil Rate . Min. /in drop 2qc� �+ ;J0 5. . . 4' K).0? 129 Vo 3 /3 ICI,'Q 0,--Jl '5? 5 M 3 4 5 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 submitted for review. . 2) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION '?,1 rC?�ty � /F',- .�!1;��1s DEPTH HOLE NO. ( HOLE NO. HOLE NO. G.L. 6" 12" 18" A C� ` 2411 k,yl 30" 36" 4211 48" 5411 6o" 66" 72 't 78" 84" Za `�- T l�vLIxl� _LEVEL ... Tf�rCu C =ROUND T;,1, .�.. E?`ICOFR. _ INDICATE LEVEL TO WHI, WATER IEVEL RiSh& "API ER BEEING :ENCOU1NTEnr TESTS MADE BY Date DESIGN Soil Rate Usedj:�(,6 Min/l "Drop: S.D. Usable Area Provided I RA o No. of Bedrooms Septic Tank Capacity—ZQCD Gals P��iv� Absorption Area Prov ded By !31 L.F.x24" h. n .r° _q p' Address 5 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Cal. SEAL a ��'ma� �48d66 Checked by FSi otwv- Z Date PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENMOI+MR?TAL HEALTH SERVICES ` INDIVIDUAL MTER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS (Name of Owner) REVIEW SHEET - CONSTRUCTION PERMIT � � EV. !�...... DATE R G (Street Location) DOCUMENTS Permit Application Corporate.Resolution -Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets- If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of.Sewage & Expansion Area Expansion Area;shown;gravity flow,suff. size ..If Pumped Pit &-D-Box & Detailed ouse' - •..NO.�, °o - Fsa1��;~i�- =: __ :�� ..� ' �..w..:' :;�_t:..... .. _ _..� :. Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' fran Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same IMocts Std.I Rcmar]<s;.. Date: es No r LKENTS i Insp.by: 3e plans O.K. isn presoaked? pr I .. 30" pere test depthi - 3t. results for 3 runs ► dole log O.K. ,orate Affidavit for other than individual N I �.. iorization for engineer - . I er from 4 later Supply if apn icao e I ,ariance requested -such noted on plans & apps.; E ' E %PA Sy; E URTG(iE >t bEflL OI�i P_ ills y ;r DQPTN RREA' SNJI. NC Cy) NE' 1`PIAN TO 6F TRpV IoED li; >ting contours shown (show new contours) )es for driveway cuts, etc. shown ;r service line location ;ing drain, etc. location slope, bottom slope off ill N •I I (; :olation. tests and deep test pi.t location ;ic tank size and conformance to std. ,R. house minimum s setback shown ;ribution box ft- below frost A water within jQ t. of PL shown . °. • - • i `? _'CASING 12" A6oVE faRA�C' ' �•(��.j 'lan and . • ............... i 'r: •• '� - profile SDS 11 other wells and SDS closer 20 1 shown or reference made roperty boundaries (metes and bounds - clearly shown); :EGgL SuaDIV IS to ^� - i i� � }�•. - •1(1STlF,4a APPe004L �-� -- — -- -- -° EA LT`( GOBDWISIgJ 344'pUGJ Y' t WCYLANt� 114TION DISTANCES SPECIFIED ON PLAN i7 to P.L. ne / ! to Foundation walls � to Nearest well to stream, march, lake, etc. incl:expans on to Curtain drain A- I i to water line (pits -2O to storm drain I' to large trees'( from foundatirni to schtic tan: i to Pipe from leader drain &.ibocillj k1rain To -CATC4 e,ASUa ) , WELL TD _ ePTIr- TANK TO • wEL4.• d ; INITIAL SITE Ii13PECTI011 Y Y0s1 N No C Coluucnts Proporty lines or corner3 found . t tl Can . .cstin•,ate h _ Must trees be removed -hote these Is deep hole representative of entire SDS area Additional deep holes needed -. . . . . . . a . Sufficient SM area available considering ' ' driveway cut,house location, separation i i distances, etc. DO. IaGLL3 / 56PT,CS DERP HOLE DATA Dspth: Water elevation:. Rock elevation: ; ;�����,�• te: _ a a. }louse located where mshovrn on approved plan SUS located where approved . . . 1