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HomeMy WebLinkAbout2999DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17-3-52 BOX 25 ME I I ML Ll 02999 ENGINEER MUST PUTNAM COUNTY DEPARTMENT OF HEALTH PROVIDE Division of Environmentilil Halt S&Wces, Cannel, N. Y 10512 PERMIT # CERTIFICATE &F CONSTRUCTION COMPLIANCE FOR SEWAGE DISP Located at �J N •rJ,7/.!� /��� Formerly Owner Separate Sewerage System built by f 4''h"';' L Consisting of 100© Gal. Septic Tank and �d Other requirements Water Supply: Public Supply From — Private Supply Drilled BY )SAL SYSTEM u.-11`7 Town or Village. Tax Map .. � ....6•V Block Tax Map Lot 9 Address %I 24 r Subd. Lot N a a) /:I:, 4 ►�� / /r-1 , A7? av V .7 / ids - ! r Addresse'�f Building Type �° No. of Bedrooms Date Permit Issued — � Has Erosion Control Been Completed? Has garbage grinder been installed ?_ emlmo ftAhown on the plans of the completed work ( copies I certify that the system(s) as listed serving the above premises were constructed eEYeva a }y,.� of which are attached), and in accordance with the standards, rules and regulatieuay�0 a the filed plan, and the permit issued by the Putnam County Department Of Health. y Certified by ° e P.E. R.A. Date se No- - Address a unsanitary Any person occupying Dremises served by the above systems) shall promptly tak ctjQn'ms may a v 81 soon as correction any become conditions resulting from such usage. Approval of the separate sewerage.. ��p Y becomes available. Such approvals are available and the approval of the' private water supply shall become null and void �a. ,r�tjfipn, modification or change is necessary. subject, to modification or change when, in the judgment of the Commissioner of 4 n a.. •sage �-� arm Titl Date Rev. 6/85 ` n PUTNAM COUNTY DEPARTMENT OF HEALTI. _._. ENGINEER TO PROVIDE 'ZRT.I PERMIT # • .. _ Y -;-Division • . ;Diy:sivn ^vf Et;vi�t✓;,y,cr_.tr/ H?al►h C ,: Cos „9e,";° iv' "i iJl ON C F I CA•] t)I CC?�i ►,L PERMIT # -° .... .. �... �.. -«� «- CONSTRUCTION PERMIT' FOR SEWAGE DISPOSAL SYSTEM Y .. u a Gj Located at • ti /F7 rrr I�Y/YJ 1JC° �� own or i lage ¢ 6 Tax Map Block Lot Subdivision �jSubd. Lot If Renewal `0 Revision Owner /Address ~ p KNi / r_ Date Of Previous Approval Building Type Lot Area Fill Section Only ❑ Number of Bedrooms _ Design Flow G /P /D P.C. H. D. Notification Required _ Separate Sewerage System to consist of - C- t7 G Gal. Septic Tank and 4y0 Gig�l�l�jl To be constructed by �^ Address Water Supply: Other Requirements Public Supply From Private Supply to be drilled by i I represent that 1 am wholly and completely responsible foF, the tlesgn and location of the proposed above described will be constructed as shown on the a a° ”' ` pprovetl amenclment.4liere to and in accords County Department of Health, and that on completion there of,a: +Cer'tificate of Constructs be submitted to the Department, and a written guarantee will be furnished the owner, place in good operating condition any part of said sewage disposal system during the ri g ante of the approval of the Certificate of Construction Compliance of the originals a e An will be located as shown on the approved plan and that said well will be Installed in actor 9, M . County Department of Health. _�/ �/ �� Date ' � 7p Signed Address G ✓J�✓��'r7 Gr6� 1%r /.-�I APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued'1unI Sr � revocable for cause or may be amended o► modified when considered necessary by the ComnSi�rojle requires a /' /newZ15-8 permit.(!- Approved for disposal of domestif.'* \sanitary $Owage, nd •or private water.. Date "T - `I — t \w,_.. �, �� ;ystem(s); 1) that the separate sewage disposal system ndards, rules an regu a ons o the Putnam n actory to the Commissioner of Health will x°'418 0 ns by the builder, that said builder will ediately following thedate of the Issu- repairs o; that the drilled well described above Wanda ;a ul and regu a ons of the Putnam t n -- P.E. GrR.A. _ License No. k ge building has been undertaken and is ny change or alteration of construction PUIM COUNTY DEPARTMENT OF r. • • 1NVIRONKEff1!AL HEALTH, RE ArE .:UZS.L' S*AL t%__ I .: W IIE Address ra✓ Located at (.Street), sc�.m sue. �r?_ .. /- .. sec. Block !- Lot % (indicate nearest cross street) Municipality �r Watershed SOIL PERCOLATION .TEST DATA REQUIRED TO BE SUBMI= WITH APPLICATIONS Date of Pre- Soaking Date of Percolation Test HOLE NUMM CLOCK TIME PFIZCD ATION PERCOLATION Run Elapse Depth to Water From Water Level No. .. Time Ground Surface In Inches. Soil Rate Start -Stop Min. Start Stop Drop In Min/In Drop Inches Inches Inches 39 —3 .4 5 2f 4 .., 7 Rat 2 3 4 5 NOTES: 1. Tests to be repeated at same..depth until.appradmately equal soil rates are obtained at each percolation test. hole. All. data to., be sukmittt�d for review. 2. Depth measurements to be made from top of hole. rev. 9/85 TEST PIT DATA RE iUIRED TO BE:-SUBmf!!Eb-WITH APPLICATION OF SOILS ENCOUNTERED IN TEST.HOLES DEPTH HOLE NO. ' HOM NO.. Z -.-- HOLE.-NO._ 5 _F'.-3t 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED :5 DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate used Min /1" Drop: S.D. Usable Area Provided No. of Bedroans Septic Tank Capacity /®v U gals . Type Absorption Area Provided By oa00 L.F. x 24",'-width.trehch Other Name S Address 7-'? -7 2- c I . Y axff I-e 41n7 IS SPACE FOR USE BY HEALTH DEPAJM1ENT ONLY: 0 0 Soil Rate Approved sq.ft/gal. Checked by Date ___ A- - 0 n. WELL (JUV1rLJ1_11UA B-LrUAI Office Use Only :: * DEPARTMENT OF HEALTH 4*c PUTNAM COUNTY DEPARTMENT OF HEALTH WELL LOCATION STREET ADDRESS: 13WNW VItUCT/Cill TAX GRID NUMBER. SUMMIT AVE. 'PUTNAM VALLEYM, N. Y. WELL OWNER W NAME: ADDRESS. PUTNAM PHILLIP PRICE, DIANE STANNFY -.0)UMMIT AVE. 0 PBIVA'TE 011, PUI 0 PUBLIC 0 USE OF WELL 1 primary secondary .9 RESIDENTIAL ❑ PUBLIC S ' UPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 0, BUSINESS OFARM 0 TEST/ OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY 0.1 AMOUNT OF USE YIELD, SOUGHT gpm.1NO. PEOPLE SERVED. _�_6� / EST. OF DAILY USAGE -1'e90 gal. REASON FOR -B NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION DRILLING, ❑ REPLACE,EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA EP -7-7-777 f . WELD t '3 (2 t STATIC WATER LEVEL — f.1 DATE MEASURED Z A DRILLING -,g ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT ❑. WELL POINT ❑ CABLE PERCUSSION ❑ OTHER,,(specity): WELL TYPE 0 SCREENED 0 OPEN END CASING. OPEN "HOLE BEDROCK IN K - OT HER', TOTAL LENGTH ft MATERIALS: bSTtt ❑ PLASTIC' 0 OTHER WING DETAILS LENGTH.BELOW GRADE "'jOINTS:,: �'O� WELDED. 0 OTHER CI DIAMETER i . n. SEAL: ❑ PEMENT'GR . OUT. . ❑ BENTONITE O'OTHER WEIGHT PER FOOT Z-L lb./ft. I DRIVE SHOE. JRYES ONO LINER: ❑ YES JANO SCREEN S A -',! F IT..4 DIAMETER (in) 7SLOT SIZE - LENGTH (ft) - DEPTH TO SCREEN (ft) DEVELOPED? 1 0 YES' 0 Nn -P I HOURS GRAVEL -PACK 0 YES 0 NO GRAVEL SIZE. - DIAMETER OF PACK in. TOP DEPTH _t BOTTOM -DEPIN It. WELL YIELD TEST If detailed Pumping METHOD:,. 0 PUMPED 1 tests were done is in- I IQ COMPRESSED AIR formation attached? 0 BAILED 0 OTHER .1,0YES. 0-'NO .. If more detailed formation descriptions or Sieve Analyses WELL LOG are available. please attach. DEPTH FRO M SURFACE Water ing well Dia- meter I FORMATION DESCRIPTION COGE, tt. WELL DEPTH it. DURATION hr. min. DRAWDOWN It. YIELD gprn. d Sur Lanface Of WATER -9-CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? 0 YES ONO -ANALYSIS ATTACHED? 0 YES 0 NO STORAGE TANK: TYPE /,,,J_ X 7,_ CAPACITY GAL,. PUMP INFORMATION 57,.,�.,e_ TYPE CAPACITY MAKER DEPTH 49 MOOEL`:�'L kk � VOLTAGES �_20 HP 4, WELLORILLERNAME DATE P AOORESS!.,,'" x --I SlGiiAMRE b PUTNAM COUNTY DEPARTMENT OF HEALTH — DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL MUER SUPPLY SUBSURFACE S3MGE DISPOSAL SYSTEMS DATE: 5-24 -8c, nit� ntw�1) �XAK�� INSP. BY: A. (game of er) (Street Location) INITIAL SITE INSPECTION Z 0 c( M YES NO COMMEMS Wetlands on /or proximate to property .............. Property lines or corners found ................... Can estimate house location ....................... ✓ Will driveway need cut ............................ Ai 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... G O k 4 ' ;Y-8 Adjacent wells/ septics ............................ D. H. 1 Lot Depth to G.W. V Depth to rock 0 ft. 3 ft. 6 ft. 9 ft. i.r Soil Description 5QL- DATE: D.H. - Deep Hole FINAL SITE INSPECTION INS P.BY. ' YES NO G.W.- Groundwater D. H. 2 Lot D. H. 3 Lot Depth to G.W. z Depth to G.W. Depth to rock Depth to rock Soil Description Soil Descri tion 0 ft. ., 0 ft. — Z Z 3 ft. 5 y 3 ft. _ Natural soil not stripped or SDS area unnecessarly graded.......... ..... ......... 6 ft. 6 ft. 10 ft. maintained from property line and 4-- r -r 9 ft. r�r 9 ft. Distance well to SSDS (ft.) ...................... DATE: FINAL SITE INSPECTION INS P.BY. ' YES NO CAS House SSDS located per approved plan .. ....... . Length of trench measured Width of trench average Slope of tile line and trench acceptable......... V 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..... .......... 15 ft. of peripheral soil horizontally from trench ..... ............................... Boxes properly set........................... L '`� (' .� > > ✓ c Could surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... I Xis FINAL GPMNG OF SITE ACCEPTABLE.. .... PUTNAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .... :�.:'..,. .,�.s>.::i:w -" := .w'`, ;�w$+f -: c: v+ o: i. ^..;dP..':.Y".,.- �:v.'�.';•::�• fir'= ;.+w.+.>... -. .�e.•Y y... ,:.., :��. -.w.. :'.a :� :�.. :.i.�:.. w:.t:.' =5 ::.':.� ..r �.,.... =.. .. Owner or Purchaser of Building Section Block Lot Building Constructed by Location - Street Municipality Building Type Subdivision Name Subdivision Lot # GUARANTEE 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 operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any .� o rd- w�faY.c�_,� J. r..il i Y'D •±'(j i�ryCgY°{'.,�;,rYrr1QY� tT, 5: ...- •r..t.::l_..,- ....:.��:- .:1• .,,.... .:E3*:; � et. -..• X._,.. �'. r� - - °�-- -r.�_,.,,,. _ .t,_, �L, j _ .. 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 Environirental 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 building utilizing the system. Dated this _ day of 1997 Signature Title GenerfLl Contractor (Owner - Signature Vrp ration Wame (if .) Address rev. 9/85 mk 101 ', SWU Ad • Corporation Name (if Corp.) Address ,Q PUiW0 COUNTY DEPARD -UM OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS f DATE REVD" BY: (Name of Owner) (Street+ Location) • ��+ solQ E 0M I 0� 0� A® 0� 0� 0� O� S� Aim r �J MwN _®m MM 0� 0M 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 e � _ 2 2 `(roc 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 Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area A-r .; itT:' 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 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, ge Trees 20' to Founda s 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains_in,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' fran 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 q? �g•o tl 1 �}• +q "�' j m i ' : 5 towna ! 4cr t t r r , s•2x5' ` y��'i`t�'ih�$ I i c i"' Y� r tit t• ' i•. .gx►,.( -. t^� s- ..r.,�...o �,;.wFi - +:.�+� •.,: } «�.� -rs •• ry; t�''�"°`tw �""3:s"!t�"%"a%`YF3• °i�� a• .w"`.s+ �$ ` � -�•y } .-..�� -f.: S r }y^ ?.•°} ! xa;T } y _ ti , k �•'f' i` r '' r�a c .r +1"p..$. � � a #i _.�f� _ j i.' I �' 1 ��� y�p�. 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P ^. / ,;Y -• P.4tis,fI 4• �yr;ysi.L• i:iTC °;t:tt `.+*+'x t {tT ;�.,'tt y;k7il.f r' i 'a .. j Y.�ti t ` �� ?t) `.1.. ;:4'•! .,'Ga°:d t3�.Q" 4-- - 1 ��^yj rk''i.3 (� nip (C LOOK='G't It I : i •'£. i7" "' °s'1!3 •�A`� •'fY;..vvFS3u*'aP'L 6 4'giSai$\ i y �YCf " +i t L t r�9I •• .. !! t' d /�: ^• i ,, -. .. ,.c .. . .: ... - ,.�' "b,.SRic;- '+v';aW>..r.••,Siy9 :'_ �.s.3^?6X'c "Y?@..'FG"t•+ M.FYSA ?."'�.vC� ux�+mnna:•=aenrf..arn.a .v`..AZ•axrmyx:.. si.* a�a. aeru{ tiwmu�isws+' acmuw .a- �mmw�zana,erwTZweswam.w... - __ _ _"�° __ .`„° "�"'' _ _. ..... _.. __ - n not .t, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of r`j 1W,I Date r 1 GC %r .1/1- C ham' C Located at ��,Z9,., -�rrT (T)�1�� Section j�3 Block / Lot Subdivision of Subdv. ,Lot # ­7 Filed Map # Gentlemen: Date This letter is to authorize-w; 'e 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 e- , 147, Education Law, the Public Health Law, and the Putnam.County Sani- tary Code. Very truly yours, . Pe WE'D Signed Owne of Pro erty Counter h dI-%V '4 $ Address n= yity3, ���t1�3 °ae� p Address ` °i t;� _� Town Telephone Telephone (J`' TT AOF rotj,"Jry HEAL TN