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HomeMy WebLinkAbout2826DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www. scanyou rdocs.com 631- 589 -8100 62.09 -1 -1 BOX 24 02826 a I is 11 or .. on I P. { loll or sit 1■ 1 r Lo 02826 PUV AM COUNTY DEPARTMENT OF ,HEALTH Environments! Health Services Carmel :N Y .'10512 U1 CERT:IFICATf OF .CONSTRUCTION COIVIPLtANCE FOR SEWAGE .'DISPOSA L SYSTEM 11i'NA9U1 L y` . . Located at - Section Owner Lot Separate= Sewerage System-built by r [ ':� = J t� 7 Address I,Joob y 1 �w �l'1'2 !� Consisting 'of Gal'.-Septic Tank ;,lineal Feet X "width ,trench ' -: other requirements ' Water Supply Public Supply 'From Private 'Supoly''Drilled BY .. Address 'Building Type. mN` I�M!EU -1'G oms ✓' Date Permit Issued z 5= Has Erosion Control Been Completed? . =.. 2 1 certify that the systems) as listed serwng the above premises were co istrpc as as wn ip e_ ns•of the completed—work (copies of which are -bepartmenti attached) and in accordance with the, standards; ,rules.and' regulatigns; pla I' issu the Putnam County of Health.. Data - 7• ''�� " "' Certified by PE X. R.A. Q • No�1'Z,u Address License F� o. 42 _ bccupying''premise; by 'prompfly ecessary to the correction of any unsanitary Any person served -the above systems) shall to ei �n(� 'of e secure sanitary becomes conditions resulting from such usage. ; Approval the _separateseviera'ge.5y5te nd void .won a public sewer, available :and the. approval. of the private water supply shall become null, and _`void ,wh water upplysbecomes: available. Such approvals are subject: o modification'or cAan`ge when, in the, °judgment of the:COmm' stoner' Health; such rev T �o'; mod'rficatio.n or. change ...is. necessary ` Date BY.: Title U1 Or PQT POT COUNTY EiP ALT r� ;Nil ' Division of Rovir9ntnental Hoolth Gerlff COUNTY OFFICE; ®UII.PINQ - CA This f491W ,14 f q be by ! call r 01or and pubmitteg ttz_ Cok;,W- . t, p`ge� t; 04 ' ' �n�11l�1 9T a�f§Itl�a .,4m l� indicatino water is of satisfactory bacterial quality beflore Gertificata Qf eonsgruetion �D1P�IIffi�p j� a REPORT MUST ®E . SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION �e9 II I I 4 1 Mo, OF IM 11 ypa � AppR�SS .. )sfA. reatJ f�ardnl Ifpl04.70ot JE ! ®POD AUSINESS El l sTl ESTASlIS14ft1EMT FA�It 1-..J T94T W04 AIR OTHER §I PKV l.,.J INPUSTR1AI, CPNDITIPNI Q El ORCIfrl �Q6LLfNQ laculPl'�om � 49T�APy )4f-AIR OMPRESSED ('� CABLE OTHER - 9RC. ASIQN Q 1 940. SSION � (SpacifY) CAf IN6 DPTAIW "PT11 1190 DIAMETER ( inches) J* f WRIG"T PER FOOT I~� TFIREADW LJ 1 RILPSD Q I MY (sS via l "LD TI P4?+IL¢6D L, J . Ud9PER1 9COMPRESSEQ P. MOURS , AIR (Q•P4) YJATIgO (Sp 1€ATyol FROM &AND SURFACE- STATICe4/fy fapt) DURIN4 YIELD YE4i legq l Depth of Complotad W911 In feet 4v1gw land ovrfpset 3t? 5^ NAf�E6 LEPIDTII 9PSN T. Mlisq (1g04 44Q3 404 IAMETER F*hes) OF GRA�/EL PACKRDi Diameter of well Including gravel pack (Inches): GItA Nno.4ge► R9M11.foot P9 M PROM LAIC* OUIMACE FORg1ATION DESCRIPTION ¢ketch exact location of well with 41at4p0es, to at tgP.tlt two pormanent Igndmafks. PEST to FEET 1 If yield vans tooted at diokfeo t dQpiho during drilling, lint I-Im4 FERT GALLONS PER MINUTE DF5L A ( 7� OAT L ER L744(q V•�il.1l.A l.'.:.� Lt j� \..i ._I.i �. .,J �. JJ.t. _. _L Q 11,1 i.lI \i jj?all .1.. y I .. .. — ..��.= '\�-ta C• l t.iJ.dlri( ( /�On�L� �'iC l:E.•Ci J .. o Lion Location - \StrE�eL i3l0 ck . UfTding Type Lot _GUARANTY CIP SJ }SARA "1"1 K :731H GE SYSTEM. I represent that I am wholly and comp).etely responsible for the location, wor`va"Ianship, ,nutcrial, construction and drainage of the scwat;e ...disposal system servin` t'.lc above described property, and that it flas boon constructed as shorn on the approved plan or approved ai-,. nCili:erit L}1C rGi.O, _. anti in acc.ordanc e :ith the standards, rules and Perulat ons of the Yu.trza.m County Department of .,ealth, and hereby guaranty to the o .r.ner, his succc's- sors, h.- rs or assigns, to place in load opera t; rlo condition an _rare of said system constructed b r Ire which -fails to operate for a period of two years i:a_;lediately follo!.rinnf^ the. Cate of init -L\al use of 'he sewage disDos=.l o s i- y �y.� gem, Or any repairs :C.e by lily t0 sUCI S�rS I ..1, except h re t'.'_r'ie f a il'il "c> to operate Drop; rlY is caused by the :-r:i]_lful or ne3ligent act of the occu -- p tn.t of the buildilig utili7,in- the system. . . '11iE: u.iat:rsiz-12c:c ur ,;1i:,l aii�i ees to aCCep% us conc:i. zsiva the dc:- termination cf t-he Director of the; Division of ]"' 'n.virOn_ !e..nval Health vices of the Pilt:nani roomy Dopart —ment of Health as to ?•11het:"`_er or not tie fail1zrn of -he system to c:t_;ey ate .:,as caused by the. wi).lfu 0x nc,g'L e n t act of the occupant of the buildinc- util izing the.. syst;e� Dat-d this _ day of juG _ 192 Signature Title t ]:f core ra ti on, g �. ve narrit� and address) THR E (3) COPIE'S AI;E REQUIRE IVIIT.H. THREE., GOPiES 011' T <'!NAL PLANS BE7'F0RE CERCIFICATE OF COiIir!_'E'_'I0N WlLL BE ISSUED. _ :..GUARA.'NttTOR IS ijE QtITR 'nD TO FILE NOTICE 0r,' DATE .F c EI- OF FIiS US:� OF 5Y�7: _, 1. Division of Dzvirom- lental Hoalth . Servi.ccs, Putnatrl County Departmment of licult:. PEEKSKILL MEDICAL LABORATORY 1879 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1 DATE COLLECTED RESULTS OF EXAMINATION OF WATER OWNER •. DATE RECEIVED D�'a d -,5d' 7f CITY, VILLAGE, TOWN 6 /OR.NAME OF SUPPLY DATE REPORTED nLVOD� ccc /�'ers //l%rfshor� ,D�t (�a�r - SAMPLING POINT BACTERIA PER ML. (Agar plate count at 35 .C). 3 COLIFORM GROUP ( .) HARDNESS, TOTAL - ppm DETERGENTS - ppm NITRATES (as N) - ppm IRON, TOTAL - ppm, I- Luunlur; Ir) - mg. /1. These results indicate that the water was of a satisfactory sanitary quality when the sample was collected. Ag"o- m6 A. H. PADOVANI, M. T. (ASCP) ,P represent, that I am wholly antl completely. responsible for the designand locatio p "system(s) yl)' that the separate sewage disposaloystem above gescnbed will be.constructed,asshown on the approved amendmentah'eie ifiSc 'th the standartls, rules an regula_ions o t e u nam County, :pepaitment of Health, -.and that on completion thereof a'tCertifica f� _ *o o nce satisfactory to .the Co mmissioner.oi.Health'will. tie, submitted to the :Department, and a written: gua(antee,;will be - turnis t ne his s heirs or assigns'by the builder, that said builder' will a lace in o - - p 9 od operating :condd�on any part of said sewage` disposal sy m n� th iod o .s. ) Yea'rs imme"q�ately fo lowing hedate';of the )ssu ante of:atie •approval of "the 'Certificate :of`.Construction Compliance of " �; ri y aft e s thereto, 2). that "the. drill' well described above w 1-be located as shoi4n" on the approved plan and that said well will begin I i a' t st dards rules' and regula i�`ons' of 'the _Putnam _ I County.'Department of Health.". d P,.E %C - R A 1 �.: Address /J ry Y License N o APPROVED FOR CONSTRUCTION .This >approva1,expires' one year fromth 6' �,a structiori of the building.has been. undertaken and is W�'� re4ocable for, cause °or -riia_y be amended or modified when consider ces 'ry b e• of Health. - Any :'c a or alteration of,constructior requves;a new permit. Approved,.for disposal of ;domestic sa itar. se age, civatd', Date By Title K PUTNAM COUNTY DEPARTMENT OF HEALTH° Division of Environmental Health Services I,amel N: Y 10512 • r # ` CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM - J I i Town or Village `� r s5ubdrvtsion ^ ° {ATE Lot ' Job Owner M,2 i L r ET t✓ > <.ZiC `t�fl'� q ®r y� Building TYP6 tom- Lot Area-. �rCt':"aL?S i Number. of Bedrooms Design .Flow".'cc ® Total', Habitable Space Feet: Separate Sewerage - System to consist of ,t n + Square: Gal Septic Tank, and ''�' �� `7ar� to n1C1'� j ' l�. t"-� t 'TO be constructed b alt✓ Y F Address Water Supply Public Supply From 1. Prim e SuPPIY to be drilled by ifs Addres J ` t�l e Other ,P represent, that I am wholly antl completely. responsible for the designand locatio p "system(s) yl)' that the separate sewage disposaloystem above gescnbed will be.constructed,asshown on the approved amendmentah'eie ifiSc 'th the standartls, rules an regula_ions o t e u nam County, :pepaitment of Health, -.and that on completion thereof a'tCertifica f� _ *o o nce satisfactory to .the Co mmissioner.oi.Health'will. tie, submitted to the :Department, and a written: gua(antee,;will be - turnis t ne his s heirs or assigns'by the builder, that said builder' will a lace in o - - p 9 od operating :condd�on any part of said sewage` disposal sy m n� th iod o .s. ) Yea'rs imme"q�ately fo lowing hedate';of the )ssu ante of:atie •approval of "the 'Certificate :of`.Construction Compliance of " �; ri y aft e s thereto, 2). that "the. drill' well described above w 1-be located as shoi4n" on the approved plan and that said well will begin I i a' t st dards rules' and regula i�`ons' of 'the _Putnam _ I County.'Department of Health.". d P,.E %C - R A 1 �.: Address /J ry Y License N o APPROVED FOR CONSTRUCTION .This >approva1,expires' one year fromth 6' �,a structiori of the building.has been. undertaken and is W�'� re4ocable for, cause °or -riia_y be amended or modified when consider ces 'ry b e• of Health. - Any :'c a or alteration of,constructior requves;a new permit. Approved,.for disposal of ;domestic sa itar. se age, civatd', Date By Title K Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APTLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health - In the matter of application for _.-------- __... - - -- 1, represent that I am an officer or employee of the corporation and am authorized to act for —/, — — — — — — — — — — (name of corporation) having offices at �_. — — _ /�l,� .�_ J. _ _. _ _ _ _ _ _ Whose officers are 1 President (Name and Address) 1 Vice- President Jelowo4-A��1.../�L��� _ (Name aild rluuf'Cbb J op Secretary (Name and Address) — '. . -.TreasurAr /% ! 1 (Name and Address) and that I am and will be individually responsible for any or all acts of the corporation with respect to the approval requested and all sub- sequent acts relating thereto. Sworn to before me this �- �'K day Signed of -,,� UM- 19 � Title Nct r. _ is 1 � NO- V 903 &411/� Coroor. zate Seal l e .. Re: Property of Located at Section Block Lot�� Gentlemen; This letter is to authorize) �iLj . rJ a duly licensed professional engineer X . or registered architect (Indicate) to apply for a Construction Permit for a separate-sewerage system; to serve the above noted property in accordance with the standards,, rules or regulations as promulgated 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 P .E. , AMM UjZ J ' ` e' (Seal) Address Telephone Very truly yours, Signed wner o Property Address Tel ep one PUTNAM COUNTY DEPARTMENT OF Ii]!.ALTIi DIVISION, OF ENVIRONMENTAL HI?:ALTIi SERVICES OFFTCF,BIJTLDIIiG,CARA"?I.,, DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM. FILE NO. Owner M >Z t tj 2S V_ g-Lzo Address Located at (Street WE'51 S�AO(X -L p� Sec. Block Lot j �Indicate nearest cross s ree Municipality. PUTNAM VgLLf_j Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS 2 4 „2: 3 ? I 2 1.75' 5 2; 3 3 2: 4V % -- - � - z 2, 2 ? S 1 21,5o 7 g .1z) 3 Z3 2 2, 5`a 10 7 17 Zi z� 3 �7 3 3'0c► 3!2- i b t8 z 3 S,3 4 � z 5 3.' If I g Z I 5 Notes: l) Tests to be repeated at same depth until a roximatelyy equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth moasurements to be made from top of hole. Hole Number CLOCK TIME PERCOLATION PERCOLATION' Run No. Start -Stop apse Time Min. Depth, to Yvdter From Ground Surface Start Stop Inches Inches water Level in Inches Drop in Inches Soil Min. /in Rate drop ao 2 0 3:13 12 2L 2- :z 12 - 3 :a 42 7 -20 2Z . 1 02 16 2 4 „2: 3 ? I 2 1.75' 5 2; 3 3 2: 4V % -- - � - z 2, 2 ? S 1 21,5o 7 g .1z) 3 Z3 2 2, 5`a 10 7 17 Zi z� 3 �7 3 3'0c► 3!2- i b t8 z 3 S,3 4 � z 5 3.' If I g Z I 5 Notes: l) Tests to be repeated at same depth until a roximatelyy equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth moasurements to be made from top of hole. TEST PIT DATA RI QUIRT ?D TO ILL SUBM]:'PT.I D W]:TII APPLICA`.PION DESCRIP']'TOId OI SO]'LS IN '.iT,,ST HOLES . DEPTH HOLE. N0. I HOLE NO. HOLE NO. 6n ®RGA C kA M 12" L °aktA 18" 2411 t 36.. SOND VLAVC-L 4211'' 48" n 66!. 72•• .7811 84" INDICATE "LEVEL AT WATCH GROUND WATER IS ENCOUNTERED �G~ r�/ INDICATE _LE`,rEt !'0 WHICH WATER LEVEL RISES AFTER BEING EICOUNTERED TESTS MADE BY ,�..c�.,_ Date Ad/V­ Tz ._.._._ .,....�_... - -- llESIGN Soil Rate Used $ Min/1 "Drop: S.D. Usable 'ded 5006 Q. Fw of Bedrooms �P No: � Septic Tank Capacity 04 0' D v�1� .A• ;� corvcrz,�Tc Absorption Area Pr- rove ded, By 373 L. F. x24" Address 2. Z 3 K /+TC wAjA hyr N•iC�N�Li� IVc i. l ©:S 3b THIS SPACE FOR USE BY HEAUPH DEPARTP -1rNT ONLY: Soil Rate Approved sq. Ft /Gal. Checked by_