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HomeMy WebLinkAbout2786DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -2 -3 BOX 24 . -No .1 ELI, mu 7 1 P SITE IACATION y� A :A EMN /4 MAILING ADDRESS N J i7kA /K_ V , Ad Vii -u.c % r fNe C-4 . L O S� Z'7 AW O 2-Z PHONE 5-7-9-,—(6(J0 (2c (j& 21$ 42, —,2-3 PERSON INTERVIEWED PCHD Complaint # Name &Relationship (i.e, owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER w A111h 6 CAT PHONE REGISTRATION # j 34L Pro (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. ® U"O," cc rc hC Zf e t .O c <- 50-AL c e / e Proposal appr ed Proposal Disapproved 's Siqnature & Title 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 d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. s l�l�b Date (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, SIGNATURE r reported agent of - J . pIJ- owner agree to the above TITLE conditions. �./�il DATE �Z PM: %kite (FM); Yfficw (fin EI); Pink UCplirsnt) i EX t.5-r/ K 6 Cc K c a.c rc— T4-69-, df A LF Vi�0 2 n�_,cc< ci qi "jC £k�s'ruiG E'-Of -A'ddc o 5 �� �d 0 14o v.J4 il- Q..(..> /t /;L 6 c.• E C - c, /yf I Y (3' vt A A 22. V1. i W 1.4 .(Do i ?t N., 4 le C it 1404 A, n,i ti tA 40 : ck 1, PZA It a A. -Vij Too-( IN, "A I T A 1AC L D 15 3 1 N k tA., AA po 4 .0 V 64 .1 .141 r .J, by Jir r BRUCE R. FOLEY, R.S. Acting Public Health Director DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 PROPOSED ADDITION APPLICATION = (RESIDENTIAL ONLY STREET: 2 2 tee 1&e f A V J TOWN ok� jam,/ TX MAP # NAME: ��l � .f �e 1C�j- �dZ� I PH01t � �,2� j0 % ii PCHD PERMIT # MAILING ADDRESS e 7 /C.Ia//flfC� ��1 ��1 fjt/�21 V f3 ���� �f'}l �/ % l�- % Description of Addition 1 K.Ilcken>1 I0+k- too 14S 34R fgen� Number of existing bedrooms Proposed number of bedrooms _? from Certificate of Occupancy,or Certification from Building Inspector Any addition which is considered a bedroom requires formal approval of plans (Construction Permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to PUTNAM COUNTY HEALTH DEPARTMENT, 4 GENEVA ROAD, BREWSTER, NY 10509, Phone 278 -6130 with the following information. 1. Cert'ified Check for $100.00. 2. Sketch of existing floor plan (all living area including basement, if any) Non - professional drawing is acceptable. 3. Sketch of proposed floor plan. Non professional drawing is acceptable. 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. 'Include all wells and septic systems within 200 feet of property line. Any questions please contact this office. 5. Copy of Certificate of Occupancy from Town or Certification from Building Department of legal bedroom count of dwelling. OFFICE USE Comments and /or conditions application August 1995 July 1996 (Revised) ,y i : ' ' Ot, (1�1•� �fk 4'1 tt.,. I 1 �, I �l I'�� � .r _ I fIf✓ � I'. T k 8 � I •.� I I I. '!'� ='�4 ::tr �t ; I t� 1. r h�� r ; . r_ �.• +t., % � �_ y. .... _ _ - ..... .- .- . Ljjj«<TTT..xt.�+a '7, �^� ll� � r i ei � �`.c•,x � �-r'-i , ? • �' � ' .. I��. � .� . -. 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I' .off' • � `' a, b M p' ., �+ ��, � • .� s,(�`"r•. I fie► �y ,` - % ' G_Y �V, ' (; r. �r • r !� II � S � r�'. „ �', '1! " � ', 'l mss• 4'1,40V t �r '';' � •:�� It '-�' .• �.Sylr`he•f1('jY. I � l /;. ,. .. I '.l.y •('lay.`i, ^.t '4 � .I I h'tr iPK•. �� t.. `�.,. •', ,:� . ., , �.. ,: . ,,.�_ t� 1 stir f�'?• • r I � WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 Division of Environmental Hoalth Services COUNTY OFFICE BUILDING • CARMEL, NEW YORK This reaort is . to, be completed by will driller and suk�rYitted to County Health. Department together with laboratory report of analysis of�vaater sample indicating iWkei hs is skisfectory Bacterial quality before certificbte of construction - compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NjA/M�JE % �e -A t�o/Y'$' / ADDRESS ,�11 ci N4 !/,,,e "i LOCATION OF WELL lee, d Street) (Town) (Lot Number) `Ce, -,P, �e-T11 . _ vle �CJI✓1�lFf%/ 16f�/��� �t� PROPOSED USE OF WELL � BUSINESS DOMESTIC D E TAB ISHMENT CJ FARM CI TEST WELL SUPPLY D INDUSTRIAL El CONDITIONING El ((specify) DRILLING EQUIPMENT COMPRESSED CABLE (Specify) OTHER ROTARY ©A R PERCUSSION El PERCUSSION EJ (( CASING DETAILS LENGTH (feet) > DIAMETER finches) WEIGHT PER FOOT j/ �7 ' L✓� THREADED ❑ WELDED DRIVE SHOE �j ®YES ONO DYES CASING GRODU ? lJ YES ❑ NO YIELD TEST HOURS G.P.M. E BAILED PUMPED © COMPRESSED AIR YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE— STATIC(Specily feet) DURING YIELD TEST fleet) Depth of Completed Well in feet below land svrface: SCREEN MAKE LENGTH OPEN TO.AQUIFER (feet) DETAILS SLOT SIZE =ETER (Inches) IF GRAVEL PACKED: Diameter of well including gravel pack (inches): GRAVEL SIZE (Inches) FROM (feet) TO (feet) DEPTH FROM LAND SURFACEI FORMATION DESCRIPTION Sketch exact location of well with, distances, to at least two permanent landmarks.' 1 V�1 FEET 1•I 3rI 4 ` C. If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED X�' / (ATE OF y�P _ /%-/ WELL DRILLER (S lgnatu - :i,b, . - .,., - - , - fir. I �, �,--: .� "': .i , * 4 -, ,.." ..: .�: - . - .. - - * r , W. -,$.-z:"-. " - '�;4f,..-,o` S. ,.- -if, - "' -, - � . - � ..- il - � - :, " . I I :11 .� , -�. 1. I . - , ­ .�-�_.. .,., - "t-­-, 11.1 . P-1 * ., .-, I . , , - . r" , . " .."'. ., . " , , ,.,� � , ,'.� , -.:i � - ?, ,It;-; 1 I ." -1 �, , F . - - - I . 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(� -� '` - �,� �,� . 1'1:x- r. � � � . _ - .. .... � . a =.. `.J, rte/ -.. -. - ,-.. ... _ .. .,. , . ,...� t .... ^... - � ~ - -- buildil�g Constructed by Section • Location - Street Block A vLl buildiro Type Y` Lot 0 "1 GUARANTY OF SEPARATE S17� ?AGE SYSTEM I represent that.I am wholly and completely responsible for the location, iorRmanship, . material, construction and .drainage of the sec ;gage disposal system ;erving the above described property, and that it has been 'constructed as shown on :he approved plan or approved amendment thereto, and in accordance with the standards. pules and reo lations of the Putnam County Department of Heall.h, and hereby guaranty :o the owner, his successors, heirs or assigns, to place in good op-crating condition my part of said system constructed by me which fails to operate for a period of ttvo ears immediately following the date of initial use of the sewage disposal system, or :ny.repairs made by me to such system, except where the failure to operate properly ti CnUSeii .ljv 'Llle LJilliul U1 of iJie 0uk-: ii.,aii � vi uii uii - � :.: -; •fie n. �,C i.`M, The undersigned further agrees to accept as conclusive the determination f the Director of the Division of Environmental Health Services of the Putnam Cou11 t.''.1' apartment of Health as to whether or not the failure of the system to operate was lit cn�i ...h�� i_hrn j 'ti_a �_ f1.... or n ^..^o -�, 1oCnat <.^ : .^{- tle C .^C'u(:u:;t oi the ` Ju i�x ili no ystem. + -19 % ated this day of � Signature Xx,U A -� .✓ ' L- �',' ' Title - ,/� r if corporation, give name and addreS- ----------------- -------------------------------- __ -�'-� 7l' --- _- __-- _- fIREE (3) COPIES ARE REOUIRED I ITII THREE (3) COPIES OF FINAL PLANS' 13EI70RE CERTIFICATE P COMPLETION WILL BE ISSUED. .11 RANITOR TS REOUIR D TO. FILE NOTICE OF DATE Or- TIRST USE OF SYSTEM. ---------------------------------- _ ____ _______ __ __ __ _ ___ ______ ___-- __- __- _- _ - - -__ ivision of Environmental Health Services, Putnam. County Department of }Iealth ' I i PUTNAM COUNTY DEPARTMENT OF HEALTH Division of 'Environmental Health Services, Carmel, ` N. Y 10512 CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM ?UT t— t�E4r.• `� own or Vmage —• Located at K F� U �: i l-lC.i li c„J Section irk Subdivision tb ©S W K- Lot Z-3 10 Job S-13 )O 84 - Owner l_ - 5 C- Address t Building Type Lot Area 1 AG Number of Bedrooms Separate Sewerage System to consist of 120 Gal. Septic Tank To be constructed by ""C-0 t'a¢/�sltot- --o Total Habitable Space 1 S ° © Square Feet Z35 lineal feet X width trench Address Water Supply: /Public Supply From Private Supply to be drilled by Address Other Requirements I represent that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved'a mend ment there to and in accordance with the standards, rules an regulations o e u nam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of'Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder,, that said builder will place in good operating condition any part of said sewage disposal system during the period of two (2) years immediately followingh'date- of the issu- ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) `that the drilled -well described above will be located as shown on the approved plan and that said well will be installed in accordance with the standards rules and reg—Ma i� ons of the Putnam County Department of Health. Date ,S'-O L'� .1) Signed ( , �y P R.A. .E.' y� Address <-• J `�/'��l ` "' Licen No. APPROVED FOR CONSTRUCTION: This. approval expires one year from the date issued unless construction of a building has been undertaken and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction requires-6 PPnew permit. Approved for disposal of domestic �Sspiitary sewage, and/or private water supply only. /116— 1 Date OCt �� Q 7 By a- �-S�-�s. rno Title A PEEKSKILL MEDICAL LABORATORY 1879 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1 ....... Peekskill. New .York 10566 PE. T8777. 4680 - DATE COLLECTED RESULTS OF EXAMINATION OF WATER lo/15/74 OWNER DATE RECEIVED Val Pete Construction Corp.,10 Grandview Ave., Ardsley 10/16/74 CITY, VILLAGE, TOWN VOR NAME OF SUPPLY DATE REPORTED Lot 10, Block 7, TM # 62 10/18/74 SAMPLING POINT We, I BACTERIA PER ML. (Agar plate count at 350C). 4 COLIFORM GROUP (Most probable N6.1100ml.) less than 2.2 ES AL -ppm DETERGENTS - ppm NITRATES (as N) - ppm IRON, TOTAL - ppm FLOUH1UL (t•') - mg. /1- These results indicate that the water was yes of a satisfactory sanitary quality when the sample was collected. A: .- PAbovkm, M. T. (ASCP) e Re: Gentlemen: Property c Located at Section C©�1- Block Lot �o -tyN y Date 5 ��_ This letter is to authorize a duly licensed professional engineer. or registered architect (Indica e to apply'for.'a Construction Permit for a separate sewerage system; to. i serve the above noted property in accordance with the standards, rules or regulations as promulgate-I by the Commissioner of the Putnam County Lapai'tu,clit Ox nca Uu, ci.iiU to sign all Ilec;Casa.ry papers On my behalf in connection with this matter and to supervise the'construction of said s stem ,or:.s;.st,ems::_i zn .ccnformitjT., ��i th the pro�l��ons of. Article 145 or - 147, Education Law,. the Public Health Law, and the Putnam County Sani- tary Code. Very trul ou , 0FESSto � F/ Q� P• KE "<�` Signed a P o < <� ner of Prope_ Countersi . e s s P.E., Seal) e ep one Address 'qT entlone 4 a r.' ; E2 o , 1 . � 1 I { K + �c• i i p �'•/ t �rx 1,.f ! " +d.. 3rrf laR LSy saF v 'r }', t J. .' �. .! • . o c" ♦b 1 is �,1 s de v7l 4J� 77 I q PZ- T1, jt- PZ- ,:5c Iv FIELD CHECK LIST Date:- I&E,2022 /XY Insp. by; 16-10 --7.7 INITIAL SITE INSPECTION Yes No Comments Property lines or corners found Can estimate house location . . . . . . . . . . Will driveway need cut . .. . . . . . . . . . . Mutt trees be r-moved-note these a Is deep hole representative of entire SDS area Additional deep holes needed. . . . . . . . . . Sufficient SDS area available considering driveway cut.house location.separat-ion distances., etc . . . . . . . .. . DEEP HOLE DATA Depth: Water elevation: Rock elevation: Soils description, Date: FINAL SITE INSPECTION Ins p. by: House located where shown on approved plan SDS located where approved Width of trench average Slope of tile line and trench acceptable . . . Room allowed for expansion trenches . . . Over 50.ft.- from swamp.watercourse . . T-,Tatur-al sail --not- s Lr�pc--�-d o�o O" DS carea unnecessarily graded. 10 Ft. naintaLned from prop .line line* and 20 ft. from house Separation of trench from house well etc. follows plan . . . . . . . . . . . . . . Number of bedrooms checks. . . . . . . . . . . Stones, brush., stumps, rubble, etc. greater than 15 ft. from nearest trench 15 Ft. of peripheral soil horizontally from trench. . . . .... . .. . . . . . . . Junction boxes properly set Could surface run off from driveway., road6., ground surface., etc. channel near SDS, area. . . . . . . . . . . . . ... . . . . Does lot drainage aDDear O.K.-in area of SDS FINAL GRADING OF SITE ACCEPTABLE t, 1C,1 R E'n ENT CHECK SHETET DOOMENTS House plans 0. K. -- - - - - — Desi rn date,. Sheet Peres presoaked? Bain. 30'" pert test depth, Const. results for 3 runs_ D. Hole log 0,.K. Corporate .Affidavit for of Authorization. for engineer Letter from Water Supply i If variance requested -such I i r than individual applicable oted on plans & apps.: Meets Std.! Remarks Ye s � I ! 1kA. �4 f f DEsAILS if change is proposed,) i Existing contours shown show new contours) Slopes for driveway cuts, etc. shown ✓ ! Water service line location ✓ 1 Footing drain, etc. location I i Top slope, bottom slope of fill. 1'ercolation tests ,and deep test pit location Septic tank size and conformance to std. 3 B. R. house m:initrum i 'House setback shown L �l C.. 1 �l i'f'. i ! - 111 ) 1_.� 1'lr.�. 7t+j fr" 1s All -1,/a Gel' 'W1 L,i1]_1.l 56 i. � . of ri, i-511Uwii Plan and profile SD5 ,% f All other wells and SD' closer 2001 sho,,,n- or. reference. made. ~Property i SEPARATION DISTANCES-SPECIFIED ON PIAiv 10' to P.Z. _� rV/ 201 to Foundation walls I ✓ ! ! LOO1 to Nearest well 50' to stream, march, lake, etc.- incl . expansion 15' to Curtain drain 10' to water line (pits -201)� ! ✓ ! 15' to storm drain, 10' to large trees ! ! 110' from foundation to septic tank 5' to ripe from leader drain & footing drain V ! PUTNAM COUNTY DEPARTMENT OF HEALTH PT�i STOiI OF ENtrIROn1MG'nTm4z, HEALTH SERVICES .. - .. COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. 5"1310- V44- Owner ��L- Q�� CO (I ST. Go Address Located at ( StreetWdicate (', Sec G,�. Block_�_Lot. nearestccTross street) Municipality, ' _Watershed Q4 4r CATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Wa er Water Levei No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1 10%01 %� a*1kT-CA e. kJ 2 34— 4 1 6 , �9 o 4- 3 S 5 (o, 4" 2 to', 4 2 3 5 1 2 3 5 Notes: 1) Te'gts 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 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HO NO. HOLE NO. HOLE NO. G.L. 611 1211 1811 24" 3011 3611 V 4211 4811 5411 6011 6611 7211 78 8411 INDICATE T WHICH GROUND WATER IS EINUO INTERED A INDIC L TO WHIQH TER LEVEL RISES AF ER BEING ENCOUNTERED TEST S :TE AEBY L Date1 3 DESIGN Soil Rate Used ,6-1- Min/1"Drop: S. D. Usable Area Provided so-tnu No. of Bedrooms 4 Septic Tank capacity I Type MA fj& Absorption Area Provi ded By_2aS_L.F.x2411 th trench. her z Ilo Address Z - t J \s 1`9 -j THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: (F Soil Rate Approved Sq. Ft/Gal. Checked by. Date 1 -14CA Z K X Lamm E ch;f ,fL AN X z L 71 imcnoll BOX 07, fAiN N! (Do 'k WIN 0" �AST (OpN '-'AN! I Ak!*. I!- r F, C IC N j 4', MOM COW Z41A -r 1414 A� WA 74'k .7, Lk vl�' 4 SUM ANK too A( 44, is Ito I ,OH-D L(140 . . . . . . . . . . . T p1?,:)p0,c4 D "Ali I; ;5 8E -G6 PAF, H QI, 14411 ct iq AuNc tan f1µ4 ARl;0 f iPT 10 N I f? f NC ti Lr ---- --- I VaA AA x MYGM I BE IED IN ACI'Okl�ANCF W! !10, rwr H''LL `h "DUN -1 Y RKAULA T IQNS OF TH r A /-� C � F ['AHTMF NIT QF �IF-AL`rii. Own APPROVED,,..., SY-;TEN4 HF (t) �if4-Cli i'ly )C�L H A 4 EFARMFUT 1'h „Y. T 1: M rO Ck N 1 , f r};' A GAIJILUN 5! k'?IC f-kNK h N D -24.9 - F r 0 F ,,.3_- h T A.,'VAXImUM 0 C Tj 2 1973 PITCH ;:'r uIr' I-oi 1,jol waits I'JorocA, MAW vww� U;f%h?Kf0 VK I'MOHED Fnil' .&V DEPT. Of HEALTH Ft L I E any ION , V N! c S ; W Hl PA M FD JuMcp=4 Pat,.Lv%y P-L OVIRONMEN.TAt SER,,G6, D. SYSTEM II*,HVAL,PET'E'. CORP lAA j OSb SEPAKAWN DOW" ssm j� Laxogn vang R 'I', S N, -�, �wNFD 7- 15/ wu( wow'. ASSO X E 5 (W E '31'. WyE Items mA14.1,4 ka, <:T- r), AUL jw�Ac -I rh4P fA' G2 a �-K. t4a -7 i".,l Tv C, 2; TOWN or' Q NA, M V L 71 0990 .... . 5 J�l 0 7844_ egg 42 44'11 4- j S.4- 1-tz7— so 0, ply if F� 41191 T waits yy IMP MCC is RO fVchm 04. ALL rG rj NC YANK �r - ! I j 0 , ! : . E c-l"Al. 1.. 0 n awn.. A 1A,q 0, 13Y 13 T 1: AA Jul UP I, (P ubkm �W-j ID T waits yy IMP MCC is RO fVchm 04. ALL rG rj NC YANK �r - ! I j 0 , ! : . E c-l"Al. 1.. 0 n awn.. A 1A,q 0, 13Y 13 T 1: AA A (P ubkm �W-j T waits yy IMP MCC is RO fVchm 04. ALL rG rj NC YANK �r - ! I j 0 , ! : . E c-l"Al. 1.. 0 n awn.. A 1A,q 0, 13Y 13 T 1: AA MAP 4' C,',*x'�" LIZA -JA Ot' t G2 2 PL L) 0 NEW 4 13.10 -8,, .4