Loading...
HomeMy WebLinkAbout2803DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -2 -29.2 BOX 24 Ir ., hom 9f 99 Ir Wr f I� r dr 1 :1 a' PUTNAM COUNTY DEPARTMENT OF HEALTH Rev. 3186. Divislon of Environmental Health Services, Carmel, N.Y. 10512 Engineer Mast Pcovlde (tj P.C.H.D. Permit N` I va _ _...._ CERTIN TE OF'CONSTRUGTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM �y? 4WA" Located at /Y'/ �' MaP Block Lot yy Owner /appu am e r Yls. Cet /set ° aa Formerly Subdivision Name subAv. Lot s Melling Address 1 c' �� ✓3 L C70 t✓ Zip l G Date Permit issued g Separate Sewerage System built by /K, �� j` ° a/✓� a'2t-$ 4e Address r°' �r"/y /V " Consisting of / IV ®0' T- Gallon Septic Tank and 5 A ` Z ', L ew 4.16 Water Supply: Public Supply From Address or: Private Supply Drilled by 6 Address �vr G N Building Type o� =i —''�e� i tiy! c f ' Has Erosion Control Been Completed? T Number of Bedrooms 7 A Has Garbage Grinder Been installed? A161 Other Requirements I certify that the system(s) as listed serving the above premises were constructed ease of which are attached), and in accordance with the standards, rules and regulations, in Putnam County ,D.eppa�r�tment of Health. Date Z5r 91 Certified by Address .0 z / .OPP, /1 Any person occupying premises served by the abo sy t4 sha 1 \conditions resulting from such usage. ' Approv of the separate : available, and the approv I of the private water supply shall become \ subject to mods cation oL Change when, in the judgment of the Date 1,07i By— plans of the completed work ( copies lan, and the permit issued by the + P.E. R.A. License No. 2-4,1999 1' fid n cure the correction of any unsanitary )e n as a publ(: sanitary sewer becomes a p comes available. Such approvals are Ith, odiflcation or change If ry, I— ___ - I COG, WELL UUMFLETIUN "xur%i DEPARTMENT OF HEALTH PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only - ; All- WELL LOCATION ST WT ADDRESS: W M;x1QIy TAX GRIO NUMBER: , 7)6&2 . 4!Pf WELL OWNER N)MV ADDRESS: 1011-, FBIVATE PUBLIC USE -OF WELL 1 - primary 2- secondary a RESIDENTIAL ❑ 13LIC SUPPLY ❑ AIR/COND./HEAT PUMP 0 ABANDONED 0 BUSINESS 0 FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) C3 INDUSTRIAL 0 INSTITUTIONAL 0 STAND-BY 0 AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE Koo gal. REASON FOR DRILLING OREPLACE EXISTING SUPPLY []TEST/OBSERVATION []ADDITIONAL SUPPLY NEW SUPPLY (NEW DWELLING) [3DEEPEN EXISTING WELL Q DEPTH DATA WELL DEPTH '700 —ft.1 STATIC WATER LEVEL ft.1 DATE MEASURED DRILLING EQUIPMENT .12 "-OTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG 0 WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED 0 OPEN END CASING OOPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH tL MATERIALS: STEEL 0 PLASTIC 0 OTHER LENGTH BELOW GRADE __Zq ft. JOINTS: 0 WELDED §aJHREADED 0 OTHER. DIAMETER in. SEAL: )9CEMENT GROUT OBENTONITE ❑OTHER WEIGHT PER FOOT Ib.1ft. I DRIVE SHOE ONO I LINER: ri YES MO SCREEN ...... JETAILS—_ DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST 0 YES ONO fla MF -r ---- GRAVEL PACK ❑ YES . ❑ NO GRAVEL SIZE DIAMETER OF PACK In. I TOP DEPTH _tL BOTTOM DEPTH WELL YIELD TEST If detailed pumping METHOD: ❑ PUMPED i tests were done is in- *COMPRESSED AIR iormation attached? '0 BAILED ❑ OTHER ❑ YES 0 NO If more detailed formation descriptions or sieve analyses I WELL LOG are available, please attach. DEPTH FROM SURFACE Water Sear- ing Well Oia- meter In FORMATION DESCRIPTION coat It it. WELL DEPTH It. DURATION hr. min. ORAWOOWN It. YIELD gpm- Su d ce look ,zoo t 7 Ar _V WATER h�tLEAR TEMP. WATER T a h (TLI QUALITY ❑ CLOUDY HARDNESS QUALITY 0 CL( ❑ COLORED ANALYZED? OYES ONO 0 Col ANALYSIS ATTACHED? 0 YES ❑ NO ANALYSIS STORAGE TANK: TYPE CAPACITY GA7,._ PUMP INFORMATIOX TYPE MAKER MODEL ------- CAPACITY DEPTH VOLTAGE.— HP WELL DRILLER Na MT_ OA ADORES SIGNATURE 3/89 ^ , YML ENVIRONMENTAL SERVICES 321 Kear Street - Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 32.417714 CLIENT #: 6829 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLANGELO, CARMINE DATE/TIME TAKEN: 10/06796 11:00 #1 BARGR HILL RD . DATE/TIME REC'D: 10/07/96 14:30 PUTNAM' VALLEY, NY '10579 REPORT DATE: 10/09/96 PHONE: (914)-526-3604 SAMPLING SITE: SAME/KITCHEN TAP SAMPLE TYPE..: POTABLE PRESERVATI VES: NONE : COL'D BY: CARMINE COLANGELO ` TEMPERATURE..' . < 4C COLIFORM METH: MF DATE ` FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 10/07/96 MF T. COLIFORM ABSENT /100 ML ABSENT COMMENTS: BACT THESE RESULTS INDICATETHAT T ,(WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN[�-T��THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THEpARAMETERS TESTED, AT THE TIME OF COLLECTION. ' SUBMITTED BY:__ Albert H. Padnvani, M.T.(ASCP) Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH 66kpl�& rll-lallfelle Owner or Purchaser of Building ij Building Constructed by 2f 4e / -Fad Locatio - Street r/ Municipality ,���� Building Type ,R SERVT.CFS ;�? �;eg- Section Block Lot Subdivisjxfi Name Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTE24 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 • inn i : t ' ul "ui_ f.�- i;A' Cu tc Q� `^:c nn ,� jr t1P Tng? i�IST� sv. item, -.or _w%v 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 Environinental Health Services of the Putnam County Department of Health as to whether or not the failure of the system operate was caused by the willful or negligent act of the occupant of t p building utilizing the system. /� J y / Dated this 14'-- day of 191 Signature Title, eral ntractor ( ure Corporation Name (if Corp.) Address rev. 9/85 mk Dt��lleR, Corporation Name (if Corp.) beef WM R.'A I OG19 ess' POTNAM COUM DSPAQTPAM OF HEAR a r DhYw d �i�htaosea� Hatl1A'Seevloea. C�setd..N Y 1OSU i to Pwi Fatislt t a� CB�iIFICATS OF 00 CONSRQCItO FgR =WAGE DMOSAL SYSTEM Lofa/ed at r. / '. dw■ of vmae Saba. l,ai r _ =Tax -p' Ressiwat= ❑ >zert.tai ❑ Owna it /ApOYnnt Nallso, G.. -tea hG L -u� "G Z�04 Dote of lhriol ua Approval i� �• Town/' Ii gyp_ —� Date Subdivision Avnroved 19. Fee Enclosed A— ,n+- .70aJ /loj /aG Lot Am -4r' Fm Seetioa Oob volume JNober of Baboova _ DeNPp Flow G P D U POW NodBinfloo Is Hequked When M Is wed S.P.-ft Ssso—sup S*1as b -loss t a[ d °. 'Qdkm Sepdc Tank �a S.P.-ft - To be eniabucted by Warr :-Pa ffift Sappy Ftoet 1 represent that I am? Wholly : and ' :eompetely_retponsible'.fo► the dbsf above described will be constructed. as shown on the approved ambnt County Department of Health. and that on.t:ompletion-the►eof a' (le submttted to ttis.O.epartmbnt,. and a .written guarantee will b. Place in good operat" "condition <sny part of said sewage dispa ance of the apprwpl of the Certificate of_ Construction-Compl4 will be located as shown on the ipproied plen.and that said well wilt County Depart in of MwRh. Date 2 /f/ � Sigm Addntt APPROVED FOR CO STRUCTION: TMs appioval sxpfras two-yea I revocable for se or may be amended or modified whin considere requires &.5w i Approved for ditpoYl of domestic sonii Rev. (t / / I 10/88 oats location of the proposed systern(f)1. 1) that the separate sewage'.dispoYl s stem Nero, .to 's in ac & standard; rules & mgu ions o u nam catty of Constr n�ti satisfactory to the Comrrliaionw of Fteolthwfll bid the own assigns by the builder, that said buildw will ism duritp_ Immediately fol"Ino tM"to 'of. the isw- the origin& or r 0; 2) that,the drilled welt - described above '.,Putnam died in a _ st rues and' ipu aiions of, the y f P.E. = R.A. - ' No may' � � License the dote in �,,�i of the building .has been undertaken and is ry by the�%j��m and /oyCyjrry 39onet��ey��r,«yl alth.. Any change or Iteration of construction yvatii' tupply Only. %�j�9 Title PUTNAM COUNTY DEPARTMENT OF HEALTH . DIVI'SI'ON QF ENgTRn�vn�FrTTn.7. HE_AJTii_ 5E_'R,V.mF� -- s Date Re: Property of Located at (T)� Subdivision c Subdv. Lot # .f .� ,ter Cal Section Filed Map Block Lot Z�•� # Date /y,9 Gentlemen: This letter is to authorize a duly licensed professional engineer lv�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 1 ' - connection: with. this . r�stt.rr grad to c1.xF:c wise 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. _; r4�4 �! G� Countersigi�ned: P.E. , R/1. , Z A o Address 1 fr 5 Telephone i•-r' r. Very truly Signed S1 La ✓ems ✓Lo Address FOA-hcim �/qllq N.Y. Town 6� 9 4�- Telephone PUTNAM COMM E1• M IE OF . DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. owner Addressy Located at (Street)c/ Ys % 14 Sec. Block Loth (indiafte nearest cross street) Municipality �� %� Watershed • 1 • 2i• t• •' li e Date of Pre- Soaking 3 Date of Percolation Test HOLE NUMBER CI= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches �� 1 AV ,d 3� J-71 e, �� �3 /� %141 2/ 3// /i Ail 4 5 1 4 5 1 2 3 4 5 NOTFS: 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. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES c. :•m. T" .. _ ,..m:.a: �.- o. -,.,r. -a �. aYL7L"Yi. wN%.tl. ••.:: w ^r.•r � . � t •�..�:.- ::`pJ.. '�c-#e '�. ,` '..s ..� +5? .... , r _�.'A. <-:�ri :x..is:.m«: .� r vec ...ate G.L. g 3' G/Ct 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED 3 j INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED _�a C DEEP HOLE OBSERVATIONS MADE BY:', jy �/ �` e°�i�� DATE: 7 3j oY DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided g6e-s, J No. of Bedroams -3 Septic Tank Capacity %O Absorption Area Provided By 5-e G' L.F. x 24" width trench gals. Type Other 2 �/ � a/� sc�f P'i / 7 j C i yam% Name y,� FAA C!3 8 Address %� •QCs -t°� fir-: ✓c_ o- SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date r PC -1 0 PUT NAM COUNTY D E PART M E NT OF H EA LT H c�.A p nn�i r1F . �� R A4T �? [1T?"Ptl. A V -�T• _...... ... _ �_._... .. LT:Sti._TEO.. A._��_�r_.�An..:�... .++..t.��.; F.:f.?w�,A: -.!�. �..,EoA ":E.�., 5,.,_-s - T�,xz.M`.:,_ - - - - -. 1. Name and Address of Applicant: 2. Name of Project: 3. Location T /V /C: 4. Project Engineer: � � /�i`' ®�7 5. Address: 2307� ��'✓� s'T � License Number: Phone: 2 2 6. Type of Project: T,e`d--Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEAR)? IV"oa Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ..../�..... 9. Has DEIS been completed and found acceptable by Lead Agency? ..�,%:.. 10. Name of Lead Agency D✓% 11. Is this project in an area under the control of local planning, zoning, cv.16 Rivi ..Eti.it, ui'o� yr �Cira PEA:,? . ............................... - ......: .. __ _ - - _• 12. If so, have plans been submitted to such authorities? ........ -..... 13. Has preliminary approval been granted by such authorities ?/ !�J Date Granted: . 14. Type of Sewage Disposal System Discharge...... Surface Water Ground Waters 15. If surface water discharge, what is the stream class designation ?........ _&�A4 16. Waters index number (surface) .......... ..............,lid."........... 17. Is project located near a public water supply system? .................. Ala 18. If yes, name of water supply i✓'�- Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... Al-d 20. Name of sewage system aIA- Distance to sewage system h/;14� 21. Date test holes observed: 22. Name of Health Inspector: 23. Project design flow (gallons per day)........... . .. ....................... 11/93 2. 24. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. /E%v 25:�Has 51'`� S Application been submiitea to`ig�al DEC tree ?`'. "'. ........... 26. Is any portion of this project located within a designated Town or State wetland ?......... ..................... ............................... zs� 27. Wetland ID Number ...................... I- 28. Is Wetland Permit required? .............. ............................... MCI Has application been made to Town or Local DEC Office? 29. Does project require a DEC Stream Disturbance Permit? ................... 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, X'U landfilling, sludge application or industrial activity? ........ YES or NO 31. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO G DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ...........r_ 33. Are community water, sewer facilities planned to be developed within 15 years? 34. Are any sewage disposal areas in excess of 15% slope? ........................ Ala 35. Tax Map ID Number ............. ..... ......... 36. Approved Plans are to be returned to: .../............ Applicant A--'Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: 04� 4A �/; /-