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HomeMy WebLinkAbout2776DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -1-45 BOX 23 02776 LA 1 y 02776 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES -- iF�n -T ^n,,. � :x� a l' •Canes � . ��.•� � � ,. � .� � I ���,P�S�'�. a � �a 5,.. � Jn:t.EyD �i� � u '4'I �I-' .�� ; . •�.•: _ .- ..::�.. _ � , , ..... _ �. _ :. -FI USE ONLY '--,51 <W. d _el-e SITE LOCATION.23 54( l•' / d TM #. , 0 WNER' S NAME PHONE MAILING ADDRESS z ::� .53 fT . /f.' 4 PERSQ,N INTERVIEWED PCHD -a�� si^� �� PCHD Complaint # Name Relationship (i.e., owner, tenant, etc. DATE /0�%4lid' TYPE FACILITY ADDRESS INSTALLER 7- 1-3,47" PHONE_ REGISTRATION# 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. I, as owner, o)orted a nyof owner aeree to the conditions stated on this form. SIGNATURE TITLE DATE Proposal 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 S n treet Name, Tow and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 12-50 gal. Concrete septic tank; three precast 6 diam. X6` deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved. Inspector's Signature & Title /DAYE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML PUTNAM COUNTY DEPARTMENT OF HEALTH ON. OYENVIRONK". CERTI FffCATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # A 317 - ea R Z 4'7- 6 d Located at 23 -� #- Town or Village Owner /Applicant Name ��c.✓�G�°` . / %`� °�'/ Tax Map G 2 Block / Lot `Y- 3 Formerly Subdivision Name Subd. Lot # Mailing Address -3 Date Construction Permit Issued by PCHD A�//Y / ®a Segairate Sewerage System built by ® 6✓° h G/' Address Consisting of 11„/1°10 Gallon Septic Tank and Other Requirements: WateK Su Ry: Public Supply From Address 01r: k,' Private Supply Drilled by �'X �� %� Address Building. y e r %.. d K%A', ��` _ uas cres:3n vCx'2�. "mil t�ZeI'i Corii ie tcuf _.. _.� r Number of Bedrooms -3 Has garbage grinder been installed? �d I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: // a/ Certified by Address 5� � 9 Any pers occupying premises served yv the above to secure the correction of any unsanitary conditions re' R treatment system shall become null and void as soon as a P.E. V4 R.A. License # 4ptly take such action as may be necessary i usage. Approval of the separate sewage sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modifi tier e a is necessary. B.. Title: 3 Date: 4 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY ]DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building �f Building Constructed by 1- � 7 A4 I r� Location - Street % ,5�; d � Building Type 2 / 4j' Tax Map Block Lot TownNillage Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above- described property, and that is 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 whi,;h fails to operate for a period of two - years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment 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 �.. ' system.._;:.. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Heath 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: Month 11 Day C> Year d 1 General Contractor (Owner) - Signature Corporation Name (if corporation) Address: State Zip Title: aj_1_XA_49 Corporation Name (if corporation) Address: State Zip Form OS -97 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PIt ®P® �I' F ®I�ySEWAG DISPOSAL SYS'Y'gM ][EW� s SE ONLY 7� U60 SITE LOCATION.23 5A y* /I d TM# f -z- OWNER'S NAME Gv�'/ i_ ;Z," .arc, /-PAC PHONE MAILING ADDRESS Z _:;� .S & PERSON INTERVIEWED PCHD SU `�^-+ �� PCHD Complaint # Name Relationship i.e., owner, tenant, etc. DATE la zeoe_02�pTYPE FACILITY ADDRESS INSTALLER PHONE REGISTRATION# 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. I; as owner, or 5ported,4Xn ,of ovyTxpr agrple to thc cc.iditionz- elated on this f3tri. SIGNA TITLE DATE Proposal 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 comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title COPIES: white (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99M L D RM 'td. -. t -i� T- Iv L, 9 `2 1 . . . . . . . . . . A P fum CQUMTT orvislcm IF MflITAL HtWM SERVTrW ir A P fum CQUMTT orvislcm IF MflITAL HtWM SERVTrW ir UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . � , _ +_.•� x fY r..uv -r � •r..r. r.T. .e.•.-r� �. .�.N.n �. w.lin � w•ns '�•.'�:' ;T U.u.r .....:r'r'...yr ...n,. r -. n.rM.•.:i.r _ ... �vFA.v . . -• .. w. .. ...fit'- .r. r . c:.t- K.,...w.. ._.. ..... _ .. ._.. .... _ .._ 0 LETTER OF AUTHORIZATION RE: Property of Located at -51�fd #i er try -r G T/V�a 14 Tax Map # d2— Subdivision of Subdivision Lot # Filed Map # Gentlemen: This letter is to authorize Block j Lot �9 3' Date Filed a duly•licensed Professional Engineer ,,,"' or Registered Architect to apply for the required wastewater treatinent and/or water supply pelmit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and /or water supply systems in conformity with the provisions of Article 145 and /or 147 of the Education Law the Public Health --- _ .. . - a�cc�v;-•ci�'1u I.�� Putnam ' vui.tty SaFlaaiy L.Udc. _ ......... ,__ _. _ ,.... _.._ Very truly yours, Countersigned: Signed: . � NEB, . P.E.,l ,� , # Z L/ y (owner of Property) Mailing Address �rMailing Address: 3 aL4 'e State Zip State Zip % "telephone: <I,- Telephone: (0 Fonn LA -97 -;LQcat d v a,. Owner- rat r st. Ing Other ,rd q ui FV B6ilclirfq� Has Ero"sip'n Co t9l -Be - ( ceriify e s"em attached) and in -:a66oi ,Date n Y'�peVs6f occupy in conditions resujting frprr ..available and the apprpvi 'subJeci to':,modification � Z.-_ PEEKSKILL MEDICAL LABORATORY .1879 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1 RESULTS OF EXAMINATION OF WATER ,:2q� 75 OWNER DATE RECEIVED CITY, VILLAGE, TOWN &/OR NAME OF SUPPLY DATE REPORTED )�f -ae_ set -7-31- 75- SAMPLING POINT BACTERIA PER ML. (Agar plate count at 350C). coLIFORM GROUP (Moat probable N6./100ml.—) –RAI L -ppm DETERGENTS - Ppm NITRATES (as N) ppm IRON# TOTAL - ppm, FLOURIUE (F) - Mg./I. These results indicate that the water was yell of a satisfactory sanitary quality when the sample was - collected. . A. H. T)ADOVANI, M. T. (ASCP) el TOU'r OF PUTNAM VALLEY uV ALL I;+3ILLERS LOG AND REPORT 669 WELL DOCATION mss? street section block lot V,1EL:L OWNER -W- me_. address city or town /�e- 71 ',.,/ name address city or towfL YIELD TEST WATER 'I EVE -fir Bailed Measure J rom 1 c or i rPump ec[Y-Hr s. Statin ft L� j.`.,L, e.te. L: _leaches Yield.: 3 GPM or L DE,11TH OF JELL - Feet surrace Make: Length Diameter Plot ize `Give description of forma1-ion penetrated, such as; peat,�w Groul urface `silt, sand, gravel, clay, hardpan, shale, sandstone; grenite, etc. Include siza of gravel(diameter and sand (finer medium, course), color of material, structure (Loose, packed, cemented, soft, hard).(Ex. Oft.to 27 ft., f- ne,_ acked, ,yellow sai dl 27 ft to 134 ft_ gr�aY��r•anztei� A�- ,'A.._ ��' , i:�t,; r rti,4_scr�_L,:.,tyo� - S�c:t�h e apt •-moo, a��or of at least two permenant Landmar?pa :uate ,- Jel.1. C;)mrl.eted. � � Date of Report We 1 '. Driller ;,a signature �.1 ' L Owner. or. Purchaser of building Municipality. e>• .r.. ....�:- .c,a_.. . .•ire • 7r �� r .- -. � :,,. a a .. `- ar. w .a. _ .. a na...., as. c_c......:. a a .errM . a ....�.., > a:.�.. �...e. .s. ..,.. .n. w. •:.•e .Building. Constructed by Sep =t ax jA- ,LrjAp Location"- Street Block Building Type 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 '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 iC C�pitCr?rl by thin toi1.1 fill, nr nacrl_i_rrrnnt mr+i- of the nnniin _nn •ft of tl-,o 'hi vi.I rlinrr 11 ti 1 4 .-7inrr L_'C 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 wheth::r. nr -not the- •fai- ilure. of the system to _operate_.- as- -. caused- by the willful' or negligent act 'of "the "'occupant ot. tfie-builci'ing uti1 "zing -the s stem_ Dated this day of G 19�.j--Signature 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. GUARANTOR IS.REOUIRED TO FILE NOTICE OF DATE Or-FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health Z, ,5 r 'r 'Numberr -,of Bedrooms ,?Separate. Sewerage Syste[ Y To be. ;constructed by ;Water solii y:+ Other Requirements _ 7 represent that J;am whol 'above 'described will be co County `Departrient of `:, be submitted °to, the DeF `},place m� good operating; ante o f. the appioval ?of; will.be =located`a ,,, awn of County ,Department of H KI .Putnarn; n ,and' is. �i newnn hny cna nyv, vr auerauvn vT; consuucuon { Title PUTNAM COUNTY DEPARTMENT. OF FEA_L,TTi DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO._ r I-VI-A4,11-1 d4eZ,4' Owner � ��,��� rf6' ����i�'�j�� -.i.�' Address �i`o 4�� '/r,�:.��,� �'i�,� A/- y. ... Located at (Street c�l� y°' /�/ �7 i� . JL Block o / Lot /a�� 2.3 �indYcate nearer- cross street) Municipalityv,J SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION apse 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 4 4 5 1 3 5 Notes: 1) TeAts 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. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION T _M3 _DT�I'CPIP TO1,4 OF LSOILS EYCC73T,77 ;3 �L - T_� ERED TEST- HOT DEPTH HOLE NO. G.L. L 61t 1211 18" A t . 2411 3011 'N P47VO'f4Wj� 3611 4211 481.1 5411 60" EMS 7211 7811 HOLE NO. 10Y HOLE NO. 4( cte AVIV-0 8411 INDI WAr.r:ER TS..FNn,01Pj'mL 7.,RFD TCATE.*jE-\7�,]T - INDICATE LEVEL•TO WHICH WYAER LEVEL RISES AFTER BEING ENCOUNTERED - -, T_� - 1051woe -- 7 ':TESTS MADE BY 12— Date Soil Rate Used DESIGN JO Min/1"Drop: S.D. Usable Area Provided- No. of Bedrooms Septic -Tank Capacity VA e3 Gals Type x).. �,w . VLZCY��Z Absorption Area Provided By 17 ZL F.x2411 idth trenc LOIDE77-r- Other S I A N1 L rE "1 3o (I gna Address _q THIS SPACE FOR USE BY HEALTH Soil Rate Approved ked by L Dat 1974 PUTNA11, COUNYy 0E HEALTH ru 4 PUTNAM COUNTY DEPARTMFNT Or HEALTH L SERVICES DIVISION- OF ENVIRONNTFNTA I {EALTH Date Re :.. Property of ���.. s`�'' �= /� ,�✓ . Located at'l5iVi /o y.: %r' r Block Lot .Gentlemen: . This letter is to authorize TANLV 1. ®E 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 UU1111C1:L.LU11 W-LLli uil, iitdL�tel. dlu 10. SU[JLi'V.L8e Ule_ CUntilrucr:_lon OI Sala system or .systems in conformity with -the provisions of Article 145 or _Education Law,,.-.the Public Law an _the. ,Putnam County: San * - . _. . , ., .. :.:. -.• • :-. terry Code. �ountersig d. Very truly yours, Signed �.2cn �z_ �_�%v-•m��- --��R_ �. Owner of Property ;• 11144 Address P.E., Vic:, # 5� Address Ui J. LANUtK BOX t` 245 -2645 Telephone Telephone i y >77m-77-�n-a.v;•=.7,7 —^,nr�c.7mrarse�a- °.r..c s�- �.^.�.%'.""'.r+xyn w^°,..••..^- ,;-ri-^c ''. ti�,.".",�'",'.i�;r Syr:..- -3,•tt .• .°-mac- - a3z�'• --s - ':� i soTN DT ® HEAH P[ 3/86 Cdiaiie N.Y105�1a2 glneea s .21 -1 m s X ADIFP ®cAl c�� TEM _. PUTNAM COLMTY DEPARD ENT OF. HEALTH DIVISION OF ENVIRONIMENUM _ RFAUR. SFRVI S... _..:...._._...._ .. .......... ., .. - �l Building Constructed by ,�'�'r✓C� %�`✓ �jo��,��ii i�� �ri cam' Location - %%Street Municipality Building Type Z2,0 4-5-- Section Block Lot /°c/ g a Subdivision Name Subdivision Lot # GUARANM 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 , `Yr� f =catE� ) ',ai.-tructior C n o "�:� ��� �- `:..._.�.. �, . . �s to z !��B tail F?.. _.:P;a 7r�.:r%.l .+,i. 7 - systr'm-,. or-arly' ..�. 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 / % day of General Contract Owner) - Signature Owner or Purchaser Building �l Building Constructed by ,�'�'r✓C� %�`✓ �jo��,��ii i�� �ri cam' Location - %%Street Municipality Building Type Z2,0 4-5-- Section Block Lot /°c/ g a Subdivision Name Subdivision Lot # GUARANM 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 , `Yr� f =catE� ) ',ai.-tructior C n o "�:� ��� �- `:..._.�.. �, . . �s to z !��B tail F?.. _.:P;a 7r�.:r%.l .+,i. 7 - systr'm-,. or-arly' ..�. 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 / % day of Address rev. 9/85 mk Signature .e CAW., w%,c►4-,A- Title (��' ey- a Corporation Name (if Corp.) Address General Contract Owner) - Signature Corporation Nam6 (if Corp.) Address rev. 9/85 mk Signature .e CAW., w%,c►4-,A- Title (��' ey- a Corporation Name (if Corp.) Address YML Environmental Services 321 Kear Street, Yorktown Heights, NY-10598 -Z-r-d '73 inn-i DATE REPORTED V i4rjL&1A SA SITENG 9 h uA,, wN. \1W � y &A-VUL � \)aj(Q.4_j /AJY I U ��q /Rc;,' z � a- LAB NUMBER 32-004944 DATE/TMETAKEN For Lab Use Only _V15otable — HNO3 _pHLT2 _A,44� Nonpotable — NaOH — pH GT 9 <20>4C COLD BY STAT! HCl Na2SO3 >20C H2SO4 ZnOAc I NOTESJ I ",01M':91'1Ml2jtMV) MPN P/A X ANALYTE RESULT UNITS ALKALINITY /L VAMMONIA n-g/L CALCIUM wg/l, CHLORIDE nng/L COLOR Units CONDUCTIVITY umhos/cm COPPER rr9/L CORROSIVITY LSI --PBTE, T'NG--ENx-' FLUORIDE mg/l, HARDNESS mg/L IRO n*g/L LEAD n g/L MANGANESE. rrgx MERCURY rrg/L NITRATE n-ig/L NITRITE n-g/L ODOR TON--- X ANALYTE pH. PHOSPHOROUS SILVER. SODIUM SULFATE SULFIDE SULFITE TURBIDITY SPC TOTAL COLIFORM FECAL COLIFORM E. COLI FECAL STREP. RESULT UNITS S.U. mg/L NTU mg/L per 1.0 mL per 100 mL per 100 mL per 100 ml, per 100 ML These results indicate that the water sample [WAS] [WAS NOT] [NA] of satisfactory sanitary quality according to znAS1 the New York State Sanitary Code, for the ararn rs tested, at the time of sample collection. These results indicate ,that the w .. r s p! [WAS] [WAS. NOT] NA] ,f a satisfactory chemical quality according to t the New York State Sanitary Co re, for parameters tested, at t e bti of sample collection. p NA =Not Applicable N = Not Present (Negative) SUBMITTED BY: P Present (Positive) SA = See Attachment(s) Also done because Total Coliform was present Albert H. Padovani, M.T. (ASCP) . TNTC = Too Numerous To Count Director > = CT = Greater Than < = LT = Less Than WELL COMPLETION REPORT Office Use Only DEPARTMENT OF HEALTH " ` °'Jjivison` iif'Giivioiiinzn� dlr TealrLc� scivYC�s • ^� PUTNAM COUNTY DEPARTMENT OF HEALTH BEET ADDRESS: 75WNIVILLAGLICHY TAX GRIO NUMBER: WELL LOCATION Q p, WELL OWNER�a NAME: RESS: �� IVATE li l IBLIC o USE OF WELL 1 - primary 2 - secondary O RESIDENTIAL ❑ BUSINESS ❑ INDUSTRIAL D PUBLIC SUPPLY ❑ Al /COND. /HEAT PUMP ❑ ABANDONED ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify) O INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT i -S gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY bN SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH a ft. STATIC WATER LEVEL ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY ❑ WELL POINT ❑ COMPRESSED AIR PERCUSSION O DUG ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING ❑ OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH._ ft- MATERIALS: STEEL ❑ PLASTIC O OTHER LENGTH BELOW GRADE / X1.5 ft. JOINTS: ❑ WELDED VHREADED O OTHER DIAMETER in. SEAL: O CEMENT GROUT ❑ BENTONITE THER WEIGHT PER FOOT Ib. /it. I DRIVE SHOE O YES QWO I LINER:OYES 0 DIAMETER (in) 'SLOT SIZE LENGTH (11) 1 DEPTH TO SCREEN (11) DEVELOPED? SCREEN FIRST _ LI ET I I ' .. - ❑ YES O NO... _. SECONO� GRAVEL PACK ❑ YES GRAVEL ❑ NO SIZE: WELL YIELD TEST I If detailed pumping METHOD: O PUMPED t tests were done is in- 0,1(OMPRESSED AIR ; formation attached? O BAILED ❑ OTHER :OYES ❑ NO WELL DEPTH DURATION DRAWOOWN YIELD It. hr, min. It, gpm. a� 4�- 6_ WATER ❑ CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE HP I OF PACKR in- I TOP DEPTH tt- I OEPTHOM WELL�L� LOG 11 more detailed formation descriptions or sieve analyses are available. Dlease attach. DEPTH FROM SURFACE Water ?ear- ing well Oia- meter FORMATION DESCRIPTION cage it. ft. Land Surface STORAGE TANK: TYPE CAPACITY GAI.. WELL DRILLER NAME NAME z; G OAT 3d AOORESS ' " u 0 "% � - SltGiff=RE P•oed„ 6 sY r��l� 1PU ll 1a AM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N. Y. 90592 SEWAGE DOSPOSAL SYSTEM Permit a ��/JO� : �= Lo' ca' Ye77 'a�°'`>� {•�.'w�"- �"f���'�;�"f ..F -y�,- - ..�.... ;,�,;e,u- p,y�rro- �,tF���Hio€.a. = -.r :.-. w,.Qe " »..�.?5�.+�.'��'� a-^ Subdivision Subd. Lot A Renewal [3 Revision _[3 Owner /Address' °� ^Al iaterOf Previous Approval Building Type Lot Area J1, 7`3 Fill Section Only 13 Number of Bedrooms 3 Design Flow G /P /D �-` P.C. H. D. Notification Required Separate Sewerage System to consist of /V, 8Cy Gal. Septic Tank and s t „ o de- To be constructed by Address Water Supply: Public Supply From Private Supply to be drilled by Address Other Requirements 1' 1 represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the above described will be constructed as shown on the approved amendment there to and in accordance with the standards, ru ft! County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactic be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or a place in good operating condition any part of said sewage disposal system during the period of two (2) years nNd ance of the approval of the Certificate of Construction Compliance of the original system or any repairs the to; it will be located as shown on the approved plan and that said well will be installed in accordance with the stands® %k o ar County Department of He Ith. .° r m Date' S' netl !_ f'J Address ✓� ��� r'/�t -%i ` I APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued un less ..nstruction i e but revocable for cause or may be amended or modified when c idered necessary y the ioner of Healt h. yb requires a new permit. Approved for disposal of dome i ,y s ge, d star supply only, w�a� Date -�T By Title Rev. 9 -91 NJ �e fpi{sioner of Healthwill !d®b4�E Ider,ytfF;4 said builder will I I)o °.dYin9.6i gate of the issu- .he dfjll- _- __ej,;te1l described above I regu a o ;°o Of '.� the . Putnam , n tl?has' 4e®n�u(idertaken and Is ,Qra &14efjYlo1h of construction - ....... -.- -o - ...._.. -. .. ... -.. -.... .a. -. _... _. -.�_.. _.., .... .: -.a .¢. ... r._-- •-- a'°.- .- o- .v.w +�.. - ..�. -.- a -. .�.- ... .P.- ..a...., .... ---�. __w..�... �.. ..�...9. ..- ...e..�+...» ea J 1% PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -OLrn r^�r Qr T t T 1,� 1.--F�E E�;I�ING;:z:rARu��;.:,��. DESIGN DATA SIFT- SEPARATE �SEWAGE DISPOSAL SYSTEM FILE NO. Owner s ��-" /)�a // Address / ,00 �P Located at (Street �� %s ' Sec. 3 e Block Lot �Indicate neares- . cross .'s ree Municipality ";P, ya t �l e Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS oe Number CLOCK TIME PERCOLATION PERCOLATION Ran Elapse Depth to a er 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 4� /e ivy � 2 .4 .2 ? -) .4 5 - - .1 F4 3 4 OCT 2 91,982 5 PUTNAM COUNTY WT. OF HEALM Notes: 31 Tests to be repeated at same depth until approximately equal soil rates eL.e obtained at each percolation test hole. All data to be submitted for 21 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 E NOS i? OL1Z.- G.L. 6 1211 18" 24" 3011 36" 4211 4811 5411 6011 6611 ,721' 78" 8411 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVL RISES AFTER BEING ENCOUNTERED - . -1; Jl*-Y-0�., DESIGN Soil Rate Used ey-7-7i Min/l "Drop: S.D..Usable Area Provided e No. of Bedrooms .."31--septic Tank Capacityl loe7 e7, Gals.. Type M4 Absorption Area Provided By =:.Y b width trench.' Other iName --jo,-5 h I �a V4, V tq Addresst'72- P ae=74, i A If zfw, K- F,16-3 -a NO t7 7", THIS SPACE FOR USE BY HEALTH DEPMfTMEK 'ONLY: Soil Rate Approved l-` 'Sq. Ft./Gal.i Checked by. 00 low-, 2j� 4 *' ­O�*Date i i l y A - ,Q�. (ac-( n you w n� �r�� e�rDom r� nc� L h�us e�foom ro nch 5 +1 U, MALLta� I � - I ' tt� be. US�n 4e grit. j �Ome� end W CA well - b Etale.K . C � �k � Y. c> C 105-7 5 y { 4 i9 vat y urn �� ✓rn.�.0 � w� eaa� be � rr�r ALL ua� 4-01 0c) ebeA IT)* Ot..v- a-CAP ffy house- Ls t-iovae, s�ri�L and OhZL Uje, - Vla ve- -jv � `T1 husb�u,% �s �lorn� c m� D) Uje cls �SOaeN9II, -AL Ir-lel., Ux caf) (��CL Ohal- y tel Slb �`:ivt-4-dLi ris, go Ptexxe- S� vk �06"tl &rkc ("✓ cg3- spy � ���, cur 3 5 IOS9f i a i :a 70�� Of PliDg(faAf TAX MAP NO: 0 62- 000°01 91- 045- OC C --000 : VALLEY TAX LkTV LOCATION: 23L30 SKYE GH RD 3RD Ph RTV DIMENSIONS- ACRES- 1( of I PlAYRIAS �E : • pm 79 C= BS? SCHOOL DiSTRICT. ��a�D� .' IN j 0 ~ ' 11117g5/95 PROPERTY CLASS: '2100 LEVY DESMPT$ON T.AXA.SLE:'JA_UE TAX RATE TAX A"OVNT e (;Uuw -MAN LOU itzozo:;lovu 0 ! TUN OF (PtflNAH VALLEY 22g00 � 71o5380'00 1581o1)t I ' 325-036 IPUT VAL FXRE PROT 22270 6004&1t ®L° I331ob3 j 06 � ®O30�000�am�5�o� 0 o �� � i I TOTAL ° OWNERS CltOAP94AN CHAS F. RUTH 's! HALF TAX 2nd F3ALF TAX NAME 1EIICt(LEFt ROBIN CHAPJAA94 8 TAX COLLECTOR V:4 OF PUTNAM VI",IL:Y � $ 22 5t��7�1H 0 RD � t, ADDRESS PUN API VALLEY Rid! 105 79 , i KEEP TH9S STUB FOR:`YOUR RECORDS. ,I i ICJ X.L I.L uA -V A X—N. Ak I GENEVA ROAD BREWSTER, INTEW YORK 10509 Phone: 1-84:5-278-6130. Fax: 1-845-278-7921 FAX COVER SHEET ze FAX NUMBER TRANSMITTED TO: 2 To: /5'1' Of. From: Date: I DOCUMENTS I NUMBER OF PAGES* I 01 COMMENTS: al4ec 7 w 2-00 Mr * NOT COUNTING COVER SHEET. IF YOU DO NOT RECEIVE ALL PAGES, PLEASE TELEPHONE US IMMEDIATELY AT 845-278-6130 IV y `i,J,et w wfi� _ Vii,• � .� �.t�r `'3 .?� �F . 4. � L.. � ' V a4,.'lr 1 r P -; Yk � '� � S a � ar.+• � r L ;y� �t r �P b y� Y'" +' H'.a r: �1,� a .,;3 f 1. � ;�.,� '. 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