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HomeMy WebLinkAbout2893DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.13 -2 -17 BOX 24 02893 rW �' ' I�yL ■ N IL ' mile �ilq ma . {� . 1.6 �'T 1 1 J{ fi L� {� '� ■ ' 02893 PUTNAM COUNTY DEPARTMENT OF HEALTH } REV ' 3186(b NO Division of Environmental Health Services, Carmel, N'i.10512 OD [j,- t/ - Engineer Mdet Provide P.y � � +`j �+. P.C:H D P,,Wt .. CATE. NSTRUCTION COMPLiANCE.FOR SEWAGE DISPOSAL SYSTFJIK T� r Vlllag Town 6 Located at P BlockLot,•. Owner /appllcantName ormerly Subdivision Name Subdv: =Lof N Malting Address 1 '3 / ��� y • Zip 07:901 Date Permit Issued _ �i'?=G -4-fo e . �x eAV4-`1 A=,41 �/� G, -e%Z., k!ii / /G£�./�� /�/� 1" aj!t�: Separate. Sewerage, System: bullt by A�a Coaelstlug,of l ® 00 Gallon Septic Tank and. �� r _. Aby o Ra Water Supply: Public Sgpply From . Address or: Priv*,Sapply. Drilled by /u Abu Address f-�eC S'T Dc.sT/1 .�N1 iir�L Bulldtng Type d iL/ ri�%1 Has, Eroslon Control Been Completed? Number of Bedrooms Has Gabage Gilnder Been InstapedY D Other Requlieniente, I certify that the syetem(s) 8s li'sted serving tk,e above;prenises were constructed essentially As. shown on the plans of, the completed work ( copies of which` are- attached), and in accordance with the standards, rulas and regulations, in accordance with the filed plan, and the permit issued by the Putnam CountyDepart�nent Of H�eahtQh�.Q' .1 �; "`r Ce►tifi Y P.E. R.A. - ' Address0. -: 7 4er ..!/r License NCID:52 3 i a l es4/ Any persony occupying premises served by -the above systems s II_ Dromptly taki su h;ictbn of may be necessary to secure the correction of. any unsanitary conditions, resulting from such the Approval of the separ sevverage.systim shall become null and voidas.soon as a Dub: ?: unitary sewer becomes available and the approval .of the'Drivate water suDPly shall ^becorria null and':v'o)d when a public Water supply "comes available. Such approvals are subject to modifi tic n or change .when , In the, }udgment -of the Commissioner, of McNth',, such revocation, modification or change is,necesary, .,Date. ��� Title —7 m 4.M CAL, WzLL 5"Wirl. DL.Lu" Lxj" WL%i Office Use Only DEPARTMENT OF HEALTH ��. :zpr:..Clf�_ E?Lironmental .Hea.1tb_.Services. _ �w �0 PUTNAM COUNTY DEPARTMENT OF HEALTH t _ STREET ADDRESS IVI Gti(�j TAX GRID NUMBER: WELL LOCATION r NAME: p A /l// [NOBIVATE WELL OWNER � p PUBLIC USE OF WELL ESIDENTIAL. O PUBLIC SUPPLY O AIR /COND.IHEAT PUMP O ABANDONED 1 - primary ❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) 2 - secondary O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED EST. OF DAILY USAGES gal. REASON FOR 1K NEW SUPPLY ❑, PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION DRILLING O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH °� 00 ft. STATIC WATER LEVEL °�� ft. DATE MEASURED DRILLING ,ROTARY ❑ COMPRESSED AIR PERCUSSION O DUG EQUIPMENT ❑ WELL POINT O CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. OPEN, HOLE IN BEDROCK O OTHER TOTAL LENGTH fL MATERIALS: JWSTEEL ❑ PLASTIC D OTHER CASING LENGTH .BELOW GRADE �9 �yit. JOINTS: O WELDED $� THREADED ❑ OTHER DIAMETER in. SEAL: O CEMENT GROUT O BENTONITE 'MOTHER DETAILS WEIGHT PER FOOT 42Ib. /ft- DRIVE SHOE. 9 YES 0 NO LINER: 0 YES ,.NO SCREEN DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? - rSAi:.,...... FIRST -�.,_ ❑ YES . Q NO SECOND ......._......_._ _ �_,,.- ... __....:� .. . _'--- ---� -. -- NuUt+S - - - GRAVEL PACK ❑ YES GRAVEL DIAMETER TOP BOTTOM - ❑ NO SIZE; OF PACK in. DEPTH ft. DEPTH It. WELL YIELD TEST if detailed pum in�LL P 9 LOG if more detailed formation descriptions or sieve analyses are available, please attach. M 00: O PUMPED 1 tests were done is in- DEPTH FROM water We11 COMPRESSED AIR , formation attached? i ❑ YES ❑ NO SURFACE Bear- ing Dia- meter FORMATION DESCRIPTION poE, O AILED O OTHER tt. tt In WELL DEPTH DURATION DRAWOOWN YIELD Sur It. hr, min. ft. 9Cm• o IJ- . WATEA O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? YES ❑ NO ANALYSIS ATTACHED? YES ❑ NO STORAGE TANK: TYPE CAPACITY GAL PUMP INFORMATION TYPE ACITY WE%jERMAKEA EPTH AD MODEL OLTA HP � Yorktown Medical Laboratory, Inc. LAB # /7 0,94 -TO 321 Kear Street Date Taken: Time: /V.t, - - -. -- - Yorktown _ ��� Heiehts�.N. Y. 105 _ _ _ st Rc /�i' D e :.d � .. Time (914) 245 -3203 Date Reported. �NZ,'Ille Director: rllbcrt H. Padovani M. T. (ASCP) Collected By: Referred By: / Sample. Location: L`l! • 1�.�� Ci� p C S D A ✓(.Z.. � j ��v',n c'2 &C-1 7- (UGC- UC TP e4> iV)J7 Un7�1,1-i 1�4 1111_r&k__ P h o n e # � Phone # �T Sample Type: L / J Repeat Test? — , one) LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC NON- METALS (mg/L.) MICROBIOLOGICAL (CFU /100mL) . Acidity Alkalinity Chloride Detergents, MBAS Hardness, Total.. _ Nitrogen, Ammonia Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite METALS (mg /L) Copper Iron _ ..L:e ad ....... Manganese Mercury _ Sodium Zinc MISCELLANEOUS pH (units) _ Color (units) _ Odor (TON) Turbidity (NTU) GENERAL BACTERIA `Standard Plate Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform Fecal Coliform — Fecal Streptococcus MOST PROBABLE NUMBER TECHNIQUE' Total Coliform Index Fecal Coliform Index KEY FOR TERMINOLOGY CFU = Colony Forming Units N/A = Not Applicable LT. = Less Than ( <) GT = Greater Than (>) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non- reactive Potable _ Non- notable STP - I'lF STIP E='F Other : Sample Status: (check each) Outgoing — HNO3 _ HC1 H2SO4 NaOH T ZnOAc Na2S203 Other: Incoming 7� LE 4 °C GT 4 °C _ _ pH LE 2 ;H GE 9 — DH GE 12 _ Other: REMARKS /COMMENTS (For Lab Use) l `LAP 1110323 THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS) (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH � W YORK STATE DRINKING WATER STANDARDS,.FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. THiS­E RESULT.& INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A) MEET THE S�T��SFACTORY �,HEMICAL QUALITY STANDARDS OF THE NEW YORK STATE DRINKING WATER C�QPAS , 1]OR THE PARAMETERS TES TP,, XAT THE TIME OF COLLECTION. 2 /86(Rvsd7 /87)RWE Albert H. Padovani, M.T. (ASCP) , Director PUTNAM _COUN'T'Y DEPARTMENT OF HEALTH DI V SIGN OF "ENV RG vt ktgr EEAldR SERVICES'_ Owner or Purchaser of Building Section Block Lot Building Constructed by 2t) C GVEST S HDX-c- D(0) Location - Street P (/- W,*/s1 VAT 6 ffy Municipality ` /=f�.,fl� Building Type Subdivision Name Subdivision Lot # GUARAWEE 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 orate for a. periq -of two. years inmedia }c':y_ f,"Upwinc; thc. date of approval of: the.. _ - "Certificate of Construction Compliance" for the'sewage disposal 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 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 to operate was caused by the willful or negligent act of the occupant of the build' g utilizing the system. � I Dated this 2' d j day of, 19_,�k Signature . Title General Contractor (Owner) - Signature t3 /L L- y 15) 1 AIC Corporation Name (if Corp.) Z-/`2- &// C Ga p�, AeD Address p c)r—( V/41- l('Y /0v7 CJ rev. 9/85 mk Corporation Name (if Corp.) Address PETER C. ALEXANDERSON County Executive DEPA Division Of 110 Old. Route S *0.1/x% eNCl A /0Q!57y Dear This department is in.receipt of the above referenced project;. A review of your application will not be made until.'this -�of -f `�:' ,:', receives the required fee. (See attached fee`' schedule. j - ...ery ru yours r John,Karell Jr. .,.P.Et? Director, 7 Environmental:Health Services JK:cj 3929619190 �LIIY1rOIltltiOLBt nO8a6n JOt't7aGtNi � � waaasaw w. �uvrow_g 6i"� 110 Old Route Six Center s ...••e �RHilltop Read CRY - CITY - STATE Zli armel New Vork 95512 Putnam Valley, Now York 1 OR WED 7 CUSTOMER RECEIPT FOR PETER C. ALEXANDERSON County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 August 22, 1988 . John H. Swanson RFD 34, Geymer Dr. Mahopac,. NY 10541 Re: Compliance - Lubrano Hilltop Road . (T) Putnam Valley TM 449 -3 -6 Dear Mr. Swanson: Review of plans and other supporting documents submitted at this time relative to the above - captioned project has been completed. Comments are offered as follows: Legt:nd is missing on plans "(See 'rage 4, Item 4. of "Program Review and Policies Subsurface Sewage Disposal and Water Supply Facilities for Single Family Residences ") Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. LCW /kv r � Very truly yours, ,4, (. W-r� Lawrence C. Werper Assistant Public Health Engineer • [!.;D C- . %FRUT;i, W..PA' Public Health Director JOHN SIMMONS, M.D. Deputy Commissioner JOHN KARELL Jr., P.E. Director i� Y; PUTNAM COUNTY. DEPAR`1`'"iv * OF ,HEALTH R2 V . 3/86. Dlvisionbf Environmental Health Servlcos Carmel N Y 10512 Engineer'to Provide Penmlt N ,,yy on CERTIFICATE OF COMPLIANCE "„ 01 J��✓ CONSTRUCTION PE FOR SE E DISPOSAL. SYSTEM Permit N Tncetsd a+ _ To- wn or. Village Map Subdivision Name Sabd. Lot q Ta= Block -Lot /�" Renewal_ ❑'- Revision 0 Owner /Applicant Name�jlAIM ..G ubir4,6 }-� y Date of Previous Approval Mailing Address %��07i�YYr'f/� Town 7dp^ Ballding Type �jf77i'i7�7: Lot Area F Fll1 Seeaon Only Lj Depth Volume Number of Bedrooms / Design ,Flow G /P/D gg PCM Notlflcatlon is Required When FM is completed Separate Sewerage $ yytem to 'consi��t Hof` t / ,,G /al�lon Septic Tent an 80 �y+ To be constructed by W Nl �'!Df/ f'% Address r"r'/ 6 /% Water Supply: Pdbllo.Sapply From {� Address or: Private p ply Drilled by /y���" f'�ft2�t_Add {ease f �Y T• pZL AW , �� ��e44 Su Other Requirements 1 represent'that I am wholly and complet�iy'respgnsible for the design and IocaUon of the proposed systems) 1) that the separate sewage disposal .system above described will :be constr,ucted,as showrc;on thcappioved amendment thereio,and, .,in. accordance with the standards; rulesan regu a ions o e Putnam County .department of Health, and ihat'op completion the ­-- f a Certif�cato' "of Construction Compliance" satisfactory to the Commissionei of Health will be submitted to the Department; and a written guarantee' will be furnished -fhe 'owner, his sliccessors;.helisor auiynsDytho builder, that said builder will P lace .in good operating 'condition: any part of said sewage: disposal system during the period of two.(2)'years Immediately following the date of the Isw- ance, of the approval of .the Certificate of ConstrucLon Compliance of the original syitem'or any'repairi thereto; 2) that the drilled well described above will be locatedas shown on the approved plan,and thaYSai'd well.v+itl be 11 nstalled m! accordance with ,the ;standards, rules and regu s ions � f. ,the Putnam County DepGa�rt nt of ie�alth Date /�,0 P.E. R.A. - Address License No APPROVED FOR CONSTRUCTION This approval'expues o ear from the date issued. unless .construction of the building has been, undertaken and is a .;.v . ,. revocable for cause or may'beameridedormod�Ledwhen considered necessary) by�.the Commlisioner'of Health. -Any'changa or alteration of construction requires a now permit. pproved for disposal of "8omestic.sandary.sewage and /or supply, =�-- Date Division of Environmenrai h'ea%L1 Service,-. 'Carmel, N. Y. 70_�11 p�gh)1 SONSTRUCTION PE;;-'-4]T FOR SEWAGE DISPOSAL SYSTEM p4j 1!7a —n ko n r. e0/ LO[aletl -- _.. ... .. ._.,. _. _.. _. MAO. v i3 iOn tubd. we 1 aene.l _ t� - - .:• -•. ere ••La lain .i ._.,. ... ,. - 1 �q y�I� / . ...t /addceaa 7/IS�•r r i YI.{�I ' / {f/� y��q aq µ ✓r . r / 0 b.e. of rre.rioua aooeov.l � ^^ Building Type ' y ti ' '� ®a� Lo.c Area e r%� W Number of Bedrooms - Oeeign rlew C/1/a Separate Sewerage System to consist at -1000 Cal. 5•otie Tank To be constructed by —Y_i• Ni cYla Jell watcf Suooly; Puotic Supply From Private Supply y to be arillea Dy Address a-1 Ya of C 7 j��! 1 Other Reduieements Fx) =+- nQ _eur4sit rill secuan Only C 1. C, M. b. Nocs t:ucaon +•7wiN Purna 30o LF ' Bohr; 64 rl� Address, J l ��� Rcad n(JT?�(i /%r Va.>'fQ;, I reoresent that I am wholly and comoretety resoonsibfe for the design and location of the ,proposed syVem(sl: 1) that the separate sewage disoosal system aDove described will tre Constructea as snow,, on tn. aparoveo alit <irictm ,tj4t Here IO ifti rh CO rtlanct with the standards, rules and /CqV Nt.On3 Or the rV(nam County Department of Health, and that on completion thereof a •'C emit ioate of Construction ComolLnee° satisfactory to the Commissioner of Heutn wall be Submitted to the OODartntent, 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 dispdsaf system during the period of two (2) Years Immediately following medal• of the issu- ance of the aoorovat of trio Certificate of Construction Comotiance of the original system Or any fetsairs thereto:2) that the drilled well described above will be located as mown on the Aouroveo plan and that said well will be installed in accordance with the standards, rules and fequut.ons of the Putnam County Department of Health. Date �! T'! �/� sgne/d� l ������ P.E. R-A. Address License No. O OOZ W OS APPROVED FOR CONSTRUCTION'; This approval excites one year from the date issued unless construction of the building has been undertaken and is v reocaele for Cause, or may be amended or modified when Considered necessary by the Commissioner of Healtn, Any change or alteration of construction reeuires a ncw; permit_ ACcrovea for disposal of domestic Sanitary Sewage, and /or private water supply only. Data By Rev. 6/85 PUT-,4 AM COUNTY DEPARTMEi 1 01 a. Division of Environmental Heald) Services, Carmel, N. Y. 10512 c-r AA ._ .. Title ENG I NEER `MUST PROVIDE PERMIT n CERTIFICATE OF CONSTRUCTION COMPLIANCE'. r-,:, S., Saat flap Block i - _ ` • i 117j ®,a �6/Ltd - -- Located at �,, /' �/, ■ Sax MAP 14r- / - Subd, trot Owner e e 8 Address • ®M �1�✓� Separate Sewerage System built }�DY�'j iw r , t Conslstlnq of _.LQP= aaaal. septic Tank 90 i/ f Other requirements water Suoplyt Public Supply From Private Supply Drilled BY ' Address �ofp No. of Bedrooms` Data Permit Issued Building Type Has Erosion Centro! Been Completed? Has garbage grinder been installed? 2 certify that the ayiem(a) as listed aeP'rfltg the above premises ,,raze conatrucied essentially as shorn on cbe pl.,uss of the completed work t cc: of which are attached), and in accordance with the standards. rules and requlatiom. Sn accordance Suit'! the filed Plan. and L7• Permit issued D'; Pucn— County "OePast�jOe�aC._Of . /p$dal L'a. �• '/e • � � • -_ - P.F.— Rat. Dace CMtified D • �,q /� �e LICAnsa No Address unsay any Any 9 Sewerage ryrtam shall become null and Vold as soon as a public sanitary sewer Dec person Occupying premises served DY fns above rystem(s) shalt promptly take sue,, odic,, as noc salary to „� the correction Sanit o So Conditions resulting from such usage. Approval of trial separate Such apofovn available and the approval of the private water wholy stud become null and Vold when a public water Supply becomes available, available to d the Appon l change wean, Rt the judgment of the Commissioner of Health, suers revocation, modlflcstlon at citan9e Is necessary. Title ------ BY DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 WON Lui '� WATER WELL PCHD PERMIT # NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ili t F.tir R ( ; Fii(3;,{ TJ y �.,n�� E" •• r r. _i_ L ..� a i. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ® ON REAR OF THIS APPLICATION []ON SEPARATE SHEET (date) (signature) 11 PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue: Date of Expiration: Permit is Non - Transferrable :. 19 19 ermlt Issuing utticia Street Address Town /Village /City Tax Grid Number WELL LOCATION WELL OWNER Name Address ❑Private ❑ Public USE OF WELL O RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP 0 ABANDONED 1 - primary 0 BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY 0 AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR ONEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION DRILLING ❑REPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ODUG ®GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. ,WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES N0 NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ili t F.tir R ( ; Fii(3;,{ TJ y �.,n�� E" •• r r. _i_ L ..� a i. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ® ON REAR OF THIS APPLICATION []ON SEPARATE SHEET (date) (signature) 11 PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue: Date of Expiration: Permit is Non - Transferrable :. 19 19 ermlt Issuing utticia Receipt TOWN OF PUTNAM VALLEY N2 5644 Date ..... ................................. 1 ..... .......... Received from.J/'Ad-hs—1 ....... . ................... . . Z 0 . ....... ....................... ........... For ... ... . ...................... .............. ........ .. ...... 7 ........................................................... . ........................ Title ...... .... /... ..... DATE DESCRIPTION FUND .7 1 Receipt TOWN OF PUTNAM VALLEY N2 5644 Date ..... ................................. 1 ..... .......... Received from.J/'Ad-hs—1 ....... . ................... . . Z 0 . ....... ....................... ........... For ... ... . ...................... .............. ........ .. ...... 7 ........................................................... . ........................ Title ...... .... /... ..... DATE DESCRIPTION FUND ACCT. NO. AMOUNT PUTNAM OO_QM H TH DEPAR7 l�il. - DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of / INSPECTION NAME L U aR ti N 0 Orig. Routine ADDRESS X/1 L4 _iw , ` a 40 Street o v .. 1.,r, MAILING ADDRESS P.O. Boat Post Office Zip Code "• 6T PERSON IN CHARGE OR INTERVIEWED Name and Title DATE TYPE FACILITY TIME ARRIVED �/ t� 0 TIME LEFT r2 • tl Orig. Complain Orig. Request Compliance Complaint Camp Final Group Illness Construction Reinspection Field; Sampling Only Field Conference Other Explain FINDINGS: 2 / � / U%g ? G. �✓� I s 6- V rl M INSPECTOR: Signature and Ti PERSON IN CHARGE OR INTERVIEWID: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: TELEPHONE: VT. APPENDIX C .. FINAr+4ITE INSPECTION DateL cted by T,O TION _ . ... (� '.. V 2 _.. C?WNFR _- ) ✓,��.., ,a , _ �T # 'v 0 2 �73�I # OR SUBDIVISION LOT # (2 - CCYNI'4II�fI`S SEWAGE DISPOSAL AREA a. SDS area located as per approved plans b. Fill section - Date of placEment 2:1 barrier. LGTH WIDTH AVG . DPTH c. Natural soil not stripped VIC d.' Stone, brush, etc., greater than 15' from SDS area. Ar e. 100 ft. fran water cour etlands. SFAAGE DISPOSAL SYSTEM a. Se tic tank size 1, 00 1,250 b. Septic tank ins Zed Level c. 10' minimimi fran four tion cNi d. No,90° bends, cleanout within 10 ft. of 45° bend e. DISTRIBUTION BOX All outlets at same elevation - water tested i .. 2 ;' Protected below frost 191 O!Z.4 { 3`blinimum 2 ft. on inal soil between box and trenches f : JUNCTION BOX - properly set I g. MEL,= 1. Length required -mac) y Len installed,50 2. Distance to watercourse measured_ ft. -- 3. Installed according to plan 4. Distance center to center 5. Slope of trench acceptable 1/16 - 1/32 " /foot. 6. 10 feet from property line - 20 feet - foundations 7. Depth of trench < 30 inches fran surface 8. Roan allowed for expansion, 50% 9. Size of gravel 3/4 - 11" diameter 10 .: Depth .. of .gravel in trench .. -minim= - 11. Pi:Ue ends'- CbUp6d h, P -T OR DOSE SYSTEMS 1. Size of pug chamcer v + Cverflcw tank ?l a_rn, visoai /audio I - 'D=p e - --sily accessible Tanhole to crade 5. First box baf=leu 6. Cycle witnessed by HeaJi -th DeDartnent estimated rlcw per cycle lccat� . ce_r aocrcve" clans. - =r of r = lcc-t -- - _ _ `u plan= c. Distlance fry.. - sured `. Casing 18" acove d. S' .-ace drainace _ well i C� /Ei -LL WCMMASHIP a. Ba%eS roDer! v arc,--te t. Ail ipes r vial _ i c. All 2ipes flush. wi ti inside of box d. Backfill material contains stones < 4" in diameter e. Cartain drain installer according to plan f. Cartain drain outfall protected & dir.to exist.watercoursE- g. Fcoting drains discharge away frcm SDS area- h. Surface water 2rotection adequate i. Errosion controi provided on slopes are ter than 15 %. DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT ' A. 19A.TER WELL _ PCHD PERMIT # - WELL LOCATION Stre t Address t� �m RC'7a- Town Village City Tax Grid Number PZ17� VV-7 W - 3 f / 6 WELL OWNER -14 -4. ,� /Name I / dd ess 40rivate Y vl� L&d kw.'- -70 %3% �e ❑ Public USE OF WELL 1 - primary 2 - secondary (SIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP 0 ABANDONED (3 BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify O INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY O AMOUNT OF USE Y ELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING IMEW SUPPLY ❑ REPLACE EXISTING SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION O DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING i- s4-Ij <49 We f '♦o-- 0tnte WELL TYPE DRILLED ODRIVEN ODUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES g,- NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No.��. WATER WELL CONTRACTOR: Name 17de v".S0,17 Address: &O' Et, S—A 12U9° IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE. TO , PROPERT FROM. NEAREST WATER MAIN: LOCATION SKETCH & SOURCES.OF CONTAMINATION PROVIDED JV,4 []ON REAR OF THIS APPLICATION ❑ S FARATE,S (date) (signature PERMIT j A TO CONSTRUCT A WATER WELL This permit to construct one water well-as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. e Date of Issue: 19 Date of Expiration: Z t 19 Permit Issuing 9Wficial Permit is Non - Transferrable am DAVID D. 'BRUEN ' County Executive . . I " j - , 4 1�, is John H. Swanson RFD 7, Box 120 Geymer Drive Mahopac, New York Dear Mr. Swanson: DEPARTMENT OF HEALTH Division Of Environmental Health Services 10541 November 18, 1986 RE: Proposed.SSDS Lubrano Hilltop Road (T) Putnam. Tax Map # 49- 3712.116 JOHN SIMMONS, M.D. Deputy Commissioner Review of plans and other supporting documents submitted at this time relative tQ the above captioned project has been completed. Comments are offered as.follows: 2 more copies of:well permit application is required. I:,:have'enclosed new-triplicate-forms.. These -_must be • -- - �:.�:.�__:..... - --- o yne- µ.NY'._.c�gi ^ce�r -•;;r- " "u�,p- �- ic�.tr -..; -_. .. _.. -.. _:._ TaX Map # should be included on all documents where ridicated. In the future, 3 consistent percolation rates are require.d per perc hole. -6 ` more copy of house plans is required well detail should show grade sloping.away from well. Upon receipt of a submission., revised to reflect the above comments, this application will be considered further. AB :pt cc: AB JK Fi le Very truly yours', `Anne Bittner Asst. Public Health Engineer TWO. COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 i r _ Y J RSON, IN CfiARGE OR INTERVI,EWFD '. acknowledge receiptM;of a copy of thus SIGNATURE eld Acti.v:Ey Repor= t:......:. - TITLE PUTNAM COUNTY DEPAR'I4ENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS . .. _y.� FIELD NSPI TON ?SPORT �pp _ /� fn l f DATE: (Wajr, J)1° V • INSP. BY: (Name of Owner) (Street tion) INITIAL SITE INSPECTION I YES I NOI COMMENTS Wetlands on /or proximate to property.............. Property lines or corners found ................... Can estimate house location ....................... Will driveway need cut......... ................. Must trees be removed - note these.. ............ Deep holes representative of entire SDS area...... Additional deep holes needed...... .......... Sufficient SDS area available considering driveway cut, house location, separation distances,etc... Adjacent wells/ septics ............................ D. H. 1 Lot Depth to G. W. Depth to rock 0 ft. 3 ft. 6 ft. 9 ft. 12 ft Soil Descriotion D. H. 2 Lot Depth to G. W. Depth to rock NO Soil Descri tior 0 ft. 3 ft. 6 ft. 9 ft..., I- (f Width of trench average D. H. - Deep Hole G.W.- Groundwater D. H. 3 Lot Depth to G. W. Depth to rock 0 ft. 3 ft. 6 ft. 9 ft. -t soil Descr r DATE: FINAL SITE INSPECTION INSP.BY: YES NO COMMENTS House SSDS located per approved plan ............. Length of trench measured Width of trench average Slope of tile line and trench acceptable......... Room allowed for expansion trenches........ ..... Over 100 ft. from watercourse .................... Natural soil not stripped or SDS area unnecessarly graded.......... ... ........ 10 ft. maintained from property line and 20 ft. from house.... ........................ Distance well to SSDS (ft.) ...................... Number of bedrooms checks ......................... Stones, brush, stumps, rubble, etc., greater than 15 ft. from nearest trench.. ........... L5 ft. of peripheral soil horizontally _ frcan trench ..... ............................... Boxes properly set......... .......... ........ _ :ould surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... L ?INAL GRADNG OF SITE ACCEPTABLE.. ... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES at Re: Property of W/li /dw LU ben"i o Located at p�J747o/Y! .e / /Q1� 3 Lot / c� • /110 ('r) Section Block Subdivision of Subdv. Lot # t0 Filed Map # Date Gentlemen: This letter is to authorize VG/l�9 " ' Si�✓�irTSyi'7 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 connection with this matter and to supervise the construction of said system or systems in conformity with 147'',_ P- bli.a ue,al:th t Cpl U fox Addi -ie s s"` `—A` Y /'00)='d/ Telephone . the provisions of Article 145 or Law., _and _ the Putnam - C_ourty�Sa.ni- Very truly yours, X Signe 'ILM9-7 Owner of Pro rty 13 1 ©�cs�y •����,e p I Address Town x ;vi - a-77 - Vo233 Telephone PU31'�M COUNTY DEPAR24r-7T OF REALTH DIVISICN OF nALTH S� R CES DESIGN DAB Si��:- S`JBSJ� �;�" �c%��c• D= .c�c�Y, syS` E' , F= NO. owme~ 1r'� Wi/liOOW GubtW70 -- Address 131 /QC, 0ry L7r� y2 - Located at (street) T� / i��,C� �C7Cd Sec. Block � Lot (indicate nearest cross street) Mf u7icioality PZ/7; -7 rW j/C+ 110E44 Watersiie:l "OM PV—RCOLAST_CN T...ST DATA REQULRM TO BE SURKI= 104-1717i APPLIC- CICNNS Date of Pre- Scaking I/ / - - Date of Percolation Test 47111dra HOLE NL3�BM C =TIME PERCOLaTICN PERCOLATIC-N • Run Elaose 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 i •x •29: 1-4 �3o c . 2 " 1,4 " ,3 " 4,83 2 /.'3/ oo- /5 rylir! 2/ 24 3 5.00 3 a 5 2 2.'16: do 4 5 l 2 3 4 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rate-5 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 SbMm.ITTED W= ADPLICATION DE✓CRIPSION OF SOILS IN TEST EOLES DEr-'T3 HOLE NO HOU NO. HOLE NO. l ` 164 -Ida �,u bac/ / 2 3' 4' �a �• 61 0 /'YIQ idn x 71 �� 8' 9' ' 10' 12` 13' 14' F`MUNMR INDICATE LE,VFy TO WMCH WIAMR LEVEL RISES AF= BEING =UNTERED DEEP ROLE OBSF..RVATIONS FADE BY: DAM: DESI�I Soil Rate Used -7 Min/1" Droo: S.D. Usable Area Provided " No. of Bedroans ° Septic Tank Capacity _gals. Absorption Area Provided By _ L.F. x 24" width t=Mr-ir— -- --� - -- otner n / J ✓? N 5 Signature Aadr s QCD 7 ON O SEAL ) THIS SPACE. FOR USE BY EEALTH DEPARTMMU ONLY: ... Soil Rate Approved sq. ft/gal. Checked by —"� to DAVID D. 'BRUEN ' County Executive John H. Swanson RFD 7, Box 120 Geymer Drive Mahopac, New York Dear Mr. Swanson: DEPARTMENT OF HEALTH Division Of Environmental Health Services 10541 November 18, 1986 RE: Proposed SSDS Lubrano Hilltop Road (T) Putnam Valley Tax 'Map # 49 -3- 12.116. JOHN SIMMONS. M.D. Deputy Commissioner Review of plans and other supporting documents submitted at this time relative tq the above captioned project has been completed. Comments are offered as follows: 2 more copies of well permit application is required. I. _have .enclosed, new triplicate forms. ThQ_:.:mus_t:::bP._. - ..... ...- ..+_...,.�__ �.-... •J1 gilv�3,`._bY -n —g niae -of jglil,dcn Tax Map # should be included on all documents where indicated. • In the future, 3 consistent percolation rates are required per perc hole. • One more copy of house plans is required well detail should show grade sloping away from well. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further'. Very truly ours, Anne Bittner AB:pt' / Asst. Public Health Engineer cc :AB' JK File TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVnIONMENTAL HEALTH SERVICES ...INDIVIDUAL WATER SUPPLY & SUBSURFACE SE kGE DISPOSAL SYSTEMS REV1EW. SHEET t ntv DATE BY: (Name of Owner) (Streqt Location) ' DOCUMENTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Twoo- -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' frcan Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same WIN a� MM mm DOCUMENTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Twoo- -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Property Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' frcan Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same