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HomeMy WebLinkAbout3113DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 63. -4 -1 BOX 25 03113 .. Nil I Its IN L 'T ' I ILL titi ', r I I . JL 03113 r E:. PUTNAM COUNTY DEPARTMENT Of HEALTH r . - Division:. of Environmental Health Services, Carmel,.W. Y.: •10512.'' CERTIFICATE OF CONSTRUCTION COMPLIANCE FOIE SEWAGE DISPOSAL SYSTEM d`6 ! = Town. or Village 'Located at'.. 'K1 h ` �!' �� (� q Section Block Owner— Lot '.Joti` l (� 1y� rat Separate Sewerage System built by v� ��� Address r f Consisting of I Z Oo Gal. Sep- eptic Tank® li ,�c neal Feet � width trench. I Other requiiemerits. nf��i!e Water Supply Public' Supply From 1 Private Supply Drilled. By . Xt Address' Building Type No of'Bedrooms ` "Date. Permit Issued nn ,Has Erosion Control -Been. Completed? G I certify that.the systems) as Iisted servirig the above premises were construc4ed essentially as 'shown on th . p I aI n's of ttie completed work (copies of ,which are ,attached) and in accordance with the` standards .rules and regulations plans f�l , andhe�..ppermit i ti the Putnam. County Department of Health.' I� �Z3 9 Date f fc/ R A. ti ed �Cer � bye • P E \ Addres V\ Q License No oLL�' ti Any person occupying premises served. by the above systems) shel promptly take such action as maybe necessary to secure the correction •of any unsanitary conditions .resulting from such, .usage. .'Approval :of the :separatesewerage, systeh shall become null and void asaoon as a public sanitary sewer becomes availaple and'the.a p - p pproVal of the,,rivate'water'supply.ahall become null'and void wheri'a',. ublic water 'supply becomes a0ailable: Such approvals are i subject to modrf�ca tion'or change wheri, m the judgment of the'C loner of Health; s revocation modrficaUon or change is necasssa ;\ Date' 1 By `, Title so CITY, VILLAGE, TOWN & /OR NAME OF SUPPLY. DATE REPORTED WOOD STo RD+ PUTNAM VALLEY; NeYo 1— 15 -73 aAMPLING ,POINT FLOURIDE (F) - m4: /l: These results "indicate that t. he water was Yes r: BACTERIA PER ML (Agar plate count at'35. "C). COLI'FORM.GROUP.(Most probable No.. /100m1.) RD ES ', TOTAL - ppm Less than 20.2 i DETERGENTS - ppm NITRATES (as N) ppm IRON, TOTAL'- PPm. f FLOURIDE (F) - m4: /l: These results "indicate that t. he water was Yes r: i Owner or of Building ( .A- Building Constructed by � QtiL Municipality Section Location - Street Block © "' owak 4- Building Type Lot GUARANTY OF SEPARATE SEWAGE-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 roiLntir Den rtment- of Ncol th _ an 1---- .rc}?ir. .r_ua.r.q.nty-.. t the o:• sors,"hei'rs 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 initial use of 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 occu- pant of the building utilizing the system. The undersigned further agrees to accept,as conclusive. the de- termination of the Director of "the Division of Environmental Health Ser- vices of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willfu egl' ent act of the occupant of the building utilizing the system . Dated this Z 3 day of 19113 Signatu Title d6ww.A... / If corporation, give name and address) THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF. DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health IVELL- COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by well driller and submitted to County Health Department together with laboratory report of mullysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. I REPORT MUST B9 SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION I ADDRESS V (No. & Street).., (Town) (Lot Number) LOCATIOM J ✓ 09 MIEU BUSINESS ❑ TEST WELL FUOPOSED DOMESTIC ESTABLISHMENT FARM l J use OF PUBLIC AIR THER n CONDITIONING El O(Specify) SUPPLY INDUSTRIAL DRILLING COMPRESSED D CABLE OTHER FiQUIPPAENT ROTARY AIR PERCUSSION PERCUSSION (Spocify) SING ?jUT LENGTH (feet)– DIAMETER(Inches) WEIGHT PER FOOT I DRIVE SHOE W-3 -CA ED? cmawe NO YES NO THREADED ❑ WELDED_1 E YES D YIELD YIELD Ad , TEST. BAILED PUMPED COMPRESSED AIR WAS` MEASURE FRO M LAND jURFACE –STATIC (Soecf; 7­t; . ')1 DURING YIELD TEST (feet) Depth of Completod Well LEVEL in feet below Land surface: MAKE LENGTH OPEN TO AQUIFER (feet) SLji S Dt AME7 ER; inci4 _i)_ ­ TGRAVEL L:SIZE (inches) FZCjA-'j&e1� To (je6e) Diume;c; or wail in; I PACKED: gravel pack (inches): !Ili FROM LAND.5LlPFACE1 Sketch exact location of well with distances, to at least FORMATION DESCRIPTION two permanent landmarks. FEET. to FEET If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE ;-I WEL COMPLETED DATE OF REPORT WELL Of?4.,LER (Signature) a ' 'i t i t e f j { i I 1 D t! t) p T". 1 Q Ju /arc iryaY -StCC � JAP . 3 e. rurN j 1. OF HEALTH IT I y E, ri H 6NMONMENTAL HEALTH z � OF t�E p� SEPARATE SEWERAGE SYSTEM cl EST7` /Y'° C�'f..i c:- 'ox'C- OWtiE R': on LOEAT l ON.: yfOGO ST G T 1 , SEC. 'BLK. LOT .Siu NO TRUCKS,MACHINERY,BU1 "LDING MATERIALS NOR EXCAVATED' EARTH SHALL BE 1 / CONTRACTOR: ALLOWED IN THE SEWAGE DISPOSAL AREA. CONSTRUCTION: OF THE SYSTEM IS TO BE IN ACCORDANCE WITH THESE PLANS ANY REVISIONS THERETO AND THE P L�OLPH ROTFELD ASSOCIATES RULES AND REGULATIONS OF THE PERMIT ISSUING GOVERNMENTAL AGENCY j• AS BUILT PLAN: // B 72 SIZ'MAMARONECK AVENUE,WHI-?E PLAINS,NY d 4' ? i a 4 PUTNAM COI ;- Division of Enviion . ,d - CONSTRUCTION 'TE "RMIT . F,OR -SEWAGE ,;DISPOSA Located at = J Subdwi wnesio�n ^ a ^h or.. D��� { Budding -Type � �rLot�Arear Numtier of Bedrooms Separate Sewerage System to consist of constructed by t 5 bl ,Water - SupplY Puic .Supply From Prate; Supply. +fo be drrilled iv by .Ad ress { ` ..Other Requirements Lrepreseht that :l'am` wholly antl completely respons�blefor. the `:above; described will be; constructed as shown on the :appioved,a, ;:County Department of !Health, and that on °completion'there submitted to the �Departmeiit, and a written guarantee :w place in good ,operating condrtioh any,'part of. said sewage;, anee" of: -,t a'pp royal = of'ethe Cerlif,ieate -41,6on 'stru' -&' ° -Coi rNTY DEPARTMENT -DF HEALTH nenfal Healh Services Carmel ;N Y '10512 L SYSTEM,'* `� Section �81ock�2 l Va'obA • Address 1 n `Qy Total Habitable Space = Square feet .: r Gal Septic Tahk - lineal feet `X p width 2tr6nch � t � , C - design andjlocationrof` the ;proposed,.,system(sj . 1) ttat`A a separate- sewage iiisbosal'system nwill beaocated.as'shown "on theap'proved: plan and that said well will tie inst r'County Depart me t cf. Health .. 4 etl r £ Address l ' APPROVED FOR.CONST.RUCTION This:approvaI expires one year fror ^revocable for cause or may be amended or mod ifled' when considered' ne ce requires a new ;p it 23 Waved "posal 0ff,d6 mesticysani n 4 Date ® By .. AV satisfactory io- the,Commissioner of Healthwill or assigns by the,builder, that said builder will ears immediately following 'the.date.of the issu- liereto 2),,that the drilled'Wel4,described' above ards rule "s land :regula —ions .of , the ;Putnam, +Llcense No ©�1 of the bwldnigVhas::been undertaken and is. gny change or alterati construction '. r T•�tle , ., --� - - r PUTNALI COUNTY DE?ART'•T,NT OF HEALTH DIVISIQ, OFy£NVIRQ \iL`TAL HEALTH SED VI CES] DESIGN DATA ' SHEET - SEPARATE SE:._ai,E DISPOSAL SYSTEM: FILE NO.. Owner' 'C �J ' � j� � .J�f' Address . , bw% A' Q. Located at. (Street). Q Sec . $lock'3lo;-Z-ij Lot . . (Indicate nearest cross street) :'Municipality `� 'Watershed '�.• SOIL PERCOLATION TEST DATA REQUIRED TO BE SL'E'iITTED WITH APPLICATION 3' Hole Number CLOCK TIM PERCOLATIO\' s . PEP,COLITIO\ Run . No. Start Elapse Time Stop Min. Dept:- -o From Ground . Sur ice . Start Stogy Inches Inches ater Level in- Inches Drop in Inches Soil Rate hin/in.rop' W Z1 27 2 i 1� 37. �z: �. . z4 2 •Z 't0: dS Z I tiV 7- is . 3 tO : 4-�b All- r�� r► zA do Xe s t�'.4�j .�2 . `� 24� i 1 z 2 171-: ZJB is 2 2-4- 19 k 3' s . �s zz 2 i 1� 37. �z: �. . z4 2,7_ •Z :1 . 3 L"(0 Notes: 1) Tests to be repeated at same depth until approxi- _tely equal soil rates are ob- tained at each percolate ion test hole. all data. to be submitted for review. 2). DAnt-,i mPasi,rPmPnts to hP 'made frnm -t--)-) of },nl c, 18 Tr 24`: 3 0'; 36`r 42 `. 48 If 5 4' 60" 66" 72`' 78.E 8 4" IINDICIATE LEVE AT 4,;TIICH GROUND WATER,: LS ENC0U\TER.ED k.16 INDICATE LE L TO SyTH CH L�ATEF. LEVEL RIB =S AFTER EEING ENCOUNTERED. TESTS . ,LADE. BY,,,.. .. S. 47 Date LJi; :\ Soil Rate used lZ- Min /lT Dr.o? S: P L:� ^gg, of ?ro: i^ed _. _S tic Tan :. i tP F� No. .oi Bedroc:-s Se Cap ty pe Absorption Area Provided By L. F.x2` ' 35 .1 � n h. Other, Name W qA Address o d 1 . V :� M ��- Sim a PU TNAi I COUNTY DEPARTMENT, OF HEALTH Soil Rate Approved Sq. Ft. /Gal. Checked by p °• 421$3 7� 6 Date 7- NO TRUCKS,MACHINERY,BUILDING MATERIALS NOR EXCAVATED EARTH SHALL BE ALLOWED ll�l THE SEWAGE DISPOSAL AREA, COSTRUCTION OF THE SYSTEM Is TO BE IN ACCORDANCE WITH -THESE PLAN's AkY REV IS.101"I'S THERETO Ati'D THE .FRULES AND RFGUL,:I%TlQNS OF THE PERMIll' ISSUING GOVERNMENTAL AGENCY, CIA 7- NO TRUCKS,MACHINERY,BUILDING MATERIALS NOR EXCAVATED EARTH SHALL BE ALLOWED ll�l THE SEWAGE DISPOSAL AREA, COSTRUCTION OF THE SYSTEM Is TO BE IN ACCORDANCE WITH -THESE PLAN's AkY REV IS.101"I'S THERETO Ati'D THE .FRULES AND RFGUL,:I%TlQNS OF THE PERMIll' ISSUING GOVERNMENTAL AGENCY, 1111�, � 7 �• ,� /�KA p . - - y� �,� , � x ice...•/ GL® � �.tl. +,�.:: .. • �' ,�- �. t.J . <- 'Ong � - ti � � Dora• o. t APPR ;�_ .1 i� � Div ,..f:" :� •:i �� , �� JA n PUTN ,yip N. Or HEALTH 1 94 • �oivisiov of t•NYlRONIAENTAL HEALTH 3ERy10ES SEPARATE SEWERAGE SYSTEM 0111idER : `"5' LOLATION. )SEC�$LtCo LOT. CONTRACTOR' t PH RC�rLI:,'a.. �?SSOC 1 ATES '12 "'�it`tAR0 J1 :CK AVENUE ,WH 1 T P L A I t 4 S , NY