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 �/; /-