HomeMy WebLinkAbout3115DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
63. -43
BOX 25
03115
PUTNAM COUNTY HEALTH DEPARTMENT ; J Q r, q7
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
�." -•"- �•-. �F;`1v�'is�r' iii;~ I:2- :s2`�:r;:a�i'ar3jry..Y�iu szi►yr;:il ic:+rsl�.•- "�-� �j'"'�''jy ✓i'•
OWNER'S NAME Ae, I-Ne Cze IyAle- t/ PHONE 5-4n),. 4— 7 /Z 3
SITE LOCATION -2.87 LAJQ8 0 41%-'7- m# 6 � ` 5' -,3
MAILING ADDRESS
DATE
9 4f PaID Canplaint #
Name & Relationship (i.e tenant, etc.)
TYPE FACILITY _�j j� 5
C. PHONE H
REGISTRATION # /7
Pro (include sketc octing all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
ZZ-9& OZ22 4 /-- //� Ms 5- 4%� I- 'ro oe, -P,
//L/ �x sisJJrrls �/JS
Proposal ap4roved Proposal Disapproved _
Ins is Signat
' z
l
Proposal approved with the following conditi:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
Wiffm
(e.g. house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of x agree to the above nditions.
SIGNA TITLE ,v r DATE 94 7
/ OF -- / 7
PBS: WAbe MD); Yellow (Nn ffi); Pink Oal cznt)
�
17 lr
!
_
^ .
^-
i_
�
��---'- |
| ! !
i
� |
| | |
��-- -L-+--�--�---`'-�--�--
_
^ .
^-
i_
�
��---'- |
| ! !
i
� |
| | |
��-- -L-+--�--�---`'-�--�--
± aPUTNAM .'COUNTY DEPARTMENT'' OF HEALTH_ ,
3 .
Division •'of Envronm ta�l Hea /th SServices,r Caimel N. Y 10512
c��I
- - RTl�lr/►T� r1F /`/���cTA, +��.��n��1 n ^f�t•vCa� - r
- - .a "61`cl` Yf hit
.—Town or .Village
Located Section Block 1j
Owner �]� � � �t4�.,
Separite,Sewerage System built by
Consisting of Gal. Septic. Tank
Other irements
requ
Lour Job
Addressi3Oir�
i
lineal Feet'X width trench i
Water Supply: Public Supply - From
/ r:
+� ?Prrvate'Supply.Orrlla 8Y
dress
Bwlding Type - Oq�.t�p�► 1r1w�
Has Erosion Control Been Completed?
1 `certfy that the s,yst' ' ),as listed , 'e mises were co s aitachedj,;' and in accordance k4.- standards 'ruleand- gtlaii&
- T
`Date Ceritifi
' Address '�
Y
fCny person, occupying premises served by, the above system('s) isAall ,g
conditions resulting from' SucFi °usage " :Approval,.'of the separi! e�,s
available and the:-approvil,. of the' privafe waterasu'pply shall become;;
subjectto modification or change when,,an the- .judgmentTof the l
y
i
. . . . . . .....
N 4 s.•+� � � •{..car_- ,. . vsi.:-+ws >.o+c%•. -. _ S .. -a.- ca-r.. ....:.C- .v...ri+urr.^.c w--vw -►�'�. 7. a. a � _ r.' r -nom.
ZT
.42
0,
4
—4
V
MAR 2 31973
PUT NTRYW.. OF HEALTH
0
VISION OF
HEALTH S EIM
As
RASE SYSTEM.
4,0 4- 0 1p� StRIARATE
S. EWE RAG
OWNEIR:
q
w4o.
LOCATION., t, . 4 7
(7-)SEC, 9LK'., LOT-f.+
Al C.ONTRACTO.: N-NEP NY pa
Ul LT PLAN. :
DOLPH ROTFELD ASSOCIATES
512 KAMARONECK.AVENU.E.040.!T�' P'LA,l,NS,,NY'.'.
Q.
E
G
GUARANTY OF S'EPARATEE S S STE!,1
I represent that I am wholly and completely responsible for the
U
-te'rial. construction.and dr -e of'the.sewage
Jocation,.worlmanship, ma raina
disposal system serving the above described pro'oe'r.ty, and. that.,'it has been.
constructed as shown on the *approved bla'n.or'. a-i-o-oved amendment thereto,
and in accordance with the, s.tandards., rules and . recula ti . ons-of the Putna-m,
County Debartment of Health' and hereby -aranty to :,he owner, his succes-
sors, heirs or assigns, to place in -c-ood condition any part of
fails to operate od of two
s.aid system constructed by me which for a period V
years immediately following th6 date of initial- use of the sewage disposal'
system,.or any repairs made by rae.to such system, except- where the failure
to operate properly is caused by the willful* or neizii, --ent, act of the occu-
t-of.. the .-buildiq7, utilizing the s -:.3 t em
The undersigned further agrees U to'accent as conclusive the de-
termination of the Director of the Division of Environmental Health Ser-
vices of the Putnam Counuy Department of I He 8. 1 t'-- 1 as to whether or not the
..failure of the system to operate was caused by the willful or 1* , it
t
act of the occupant of the building utilizing .ha syste
Dated this ZZ day of V_WZ_Lk_ 19-)
-I Signature
Title
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, Putnar--County'Department of Health
BACTMIA`PER ML. (Agar. plate count at 956C):
COLIFORM:GROUP (Mostprobable No: /100m1:).:_'
LESS THAN '2. 2 . "...
ARDNESS; "TOTAL - ppm". `
DETERGENTS'- ppm
NITRATES (as N) ppm'. ,
IRON; TOTAL -" ppm
_.
:-.,;ELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTJ
3P1 Division of Environmental Health Services
COUNTY OFFI'CE IJUILLING CAnto•i., NEW YORF.
This report is to be-completed by well driller and. subt-nitted 10 COLI-ilty Hlealth Department tonether with laboratory report of
analysis of water sample indicating water is of satisfactory bacterial quality befog certificate of construction compliance is issued.
� ZFE I �i q i I "1 6 1 W"AFY, -S1 T) F
OWNER
NIME
ADDR.ESS
LOCATION
OF WELL
(No. a Street) (Town at Number)
C
------------
�:FRQFOSED
USE OF
W ELL
USINESS
DOMESTIC ESTABLISHMENT El FARM FITEST WELL
n SUP PUB! 1C LY AIR ER
P INDUSTRIAL CONDITIONING OTH
(Specify)
DRILLING
EQUIPMENT
CABLE OTHER
AIR -1
D ROTARY [;Z,. COMPRESSED PERCUSSION PERCUSSION (Spocify)
CASING
DMAILS
LENGTH (feet fDIAMETER(inches) WEIGHT PER FOOT —ov—S OE —I
THREAD[ WELDED IajyES I NO
W Wo ?
LJYE5 NO
YIEI.D
TEST
r--1 r --- I IIOURS G.PJA.
BAILED LJ PUMPE D COMPRESSED AIR
YIELD (G.P.M•)
WATER
LEVEL
MEASURE FROM LAND SURFACE — STATI (Z (Specify feet)
DUPING YIELD TEST (feet)
Depth of Completed Well
in feet below Land surfuce:
SCREEN
MAKE
LENGTH OPEN' TO AQUIrER'(feet)
DETAILS
SIOT SIZE
IF GRAVEL
PACKED:
Diameter of well including
gravel pock (Inches):
GRAVEL SIZE (inches) FRO,A (feet) TO fleoo
DEPTH FROM LAND SURFACE
DESCRIPTION
Sketch exact location of well with distances, to at loest
two permanent landmarks.
FEET to FEET
FEET
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
IFAW WELL 1A
DATE OF REPORT
WELL I)Q4-t: ER, (Signal r)
. I
L DIRIT.T. IRS LOG- AND M0=
wIm
9
wne•
,
0
,cage ogown
P.O. Address
pepth or wo11,;/-3e, uiamezer"( as well disinfecipedf
—Tta ino gpm yes Or no
jAmt. of casing -above ground /4' 'Below - --,round Woll seal
in ft packer, cement, grout
Draw a-:,.:-,,ll diagram in the space provided below and show `Jhe depth of
c: sing, the well s,lal, kind and thickness of formaj;ions enetrated, water
�bearing formations, diameter of drill holes with do-lbl�ed lines and
casing(s) with solid lined#'
WELL D I A! "7111AM FORMuMUNS PEII--:,TRAT4J" REDL , XS
:.Diameter, in. Depth l.�ind, thickness and Type of well
in f t.
Grade
't5
50
75 -
-100-
200
250
if wat.--r bearing
-�o
�.1)172.w a sketch of the property
bn the back'of this sheet locatiog
: LE L 1 D S.�WAGE DISPOSAL J.'.Z
rilling mith.od
as well dynami
btatic aazer
led * el,'ln ft.
bral ! ow .!,,,rade
pumping rate
in gpm
rumping ievei in
ft.: below ..trade
Duration of
W.L1,1:uui( I-I-X ZEi) J-
Mar-,,—ICloudy Turbid
—' id
Recommended depth of pump in
well, feet below �.--'-rade
-.1
jZL8I IN LAUTD. & GRLYSL:
and Effo size mm I
ald.eftefsize
ength of screen
iame of screen in._
ype of screen,
Drilling start.-,d C�,mplet:,d,.��.
Well Driller-;�
Si,-;nature
-.MT
'PUTNAM. COUNTY DEPARTMENT OF HEALTH -
bivision of Environmental ,H6alih.,-$�ivi'iq&,,:Cjrm"el,',,N."'Y.1 05 12 .
� I vo
CONSTRUCTION -PERMIT FOR SEWAGE DISPOSAL SYSTEM' d 'Val
Town or
Subdivision Lot, Job
Owner- _YW -b _&Lddocs Address _q �J- Y
Building Type, 0A Lot
Number of Bedrooms
Separate Sewerage system to consist of Gal. Septic Tank
To be constructed by b ar-41(i
Water Supply: Public!Supply From
Private 'Supply to be drilled ,by
Address.
Other Requirements * 5-4, 0_1 )-U0 -
I represent that I am wholly and completely responsible for the design and 16c-ation of
above described will be constructed as shown on the approved amendment there to and
County Department of Health, and that oncompletion thereof a "Certificate of
of
be submitted to the Departmeht, , and. a written guarantee will: be 1�f6rnished the
place in good ' operating condition any part of said sewage disposal system d 9
ante of the -approval of the Certificate of'Coriistructidn Cornipliance o . f the ina
st 11
and that sik! well will be Installed
will be located as shown on the approved plan
County Department of Health.
Date Signed
em(s),;�-1) thdt)�the -separate sewage disposal system
V .7 TR _
a sia,ndards, rules -an 3,regu let ions Aurnam
ad satisfactory to,the,Commissioner of Health Will
U assigns by t764-bulldpir, that said builder will
tw *:il—"'ediately following the date of the Issu-
y 8 _0 to;.2) that the drilled well, described above
st rules and reguraTro—nsof the Putnam
I Address Z I C- V V'fV%&W(;3WkK YVW
IV
APPROVED FOR CONSTRUCTION: This,approval expires one year from the.�..datNe,
---by ift
a '-p ' ift
revocable for.cause or may be m6nded.or modified When considered ne6essary,-:. the_ 54
requires a new permit. Approved for disposal of domestic sanitary seipwagjD, :arid/o*�'- 'piri
Date � frle By
MI LIcense No. K Z/19
n of the building has been undertaken and Is
Ith. Any change or alteration of construction
only.
Title
Total Habitable
Space Square Feet
lineal feet X width trench
L17FET_
Address
em(s),;�-1) thdt)�the -separate sewage disposal system
V .7 TR _
a sia,ndards, rules -an 3,regu let ions Aurnam
ad satisfactory to,the,Commissioner of Health Will
U assigns by t764-bulldpir, that said builder will
tw *:il—"'ediately following the date of the Issu-
y 8 _0 to;.2) that the drilled well, described above
st rules and reguraTro—nsof the Putnam
I Address Z I C- V V'fV%&W(;3WkK YVW
IV
APPROVED FOR CONSTRUCTION: This,approval expires one year from the.�..datNe,
---by ift
a '-p ' ift
revocable for.cause or may be m6nded.or modified When considered ne6essary,-:. the_ 54
requires a new permit. Approved for disposal of domestic sanitary seipwagjD, :arid/o*�'- 'piri
Date � frle By
MI LIcense No. K Z/19
n of the building has been undertaken and Is
Ith. Any change or alteration of construction
only.
Title
PUTNAM COUNTY DEPARTMENT OF HEALTH
Date
Re: Property of
Located at
:f
Section Block 3b - - t 3 Lot f
E
Gentlemen:
This letter is to authorize WkA
a duly licensed professional engineer or registered architect
(Indica e
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
Depai+uii,2nt Of 'iieaith, €,iiu to si ii dii iieuu8sary papers on my behalf in
-_. connection with this matter and to supervise the construction of said
system or systems in conformity . with__ the_ _prov_isions of Article 145 or _
147, Education Law, ;ya ;_Public Health Law, and the Putnam County Sani-
tary Code.
-l�
Countersigned, i
P.E.,
(peal)
Address
UfT —�2\
Telephone
Very truly y ors
9
i
Signed
Owner of :P operty
1�
w '
Ad ress
lep one
s,
am
a■
Notes:
1) Tests to be repeated at sa ^e depth until approxi -atelv equal soil rates are ob-
tained at each percolation test hole. all data to be submitted. for review.
2) Depth mea;,_,rem.ents to be made from too of hole.
PUTNA�f' COUNTY DE?A?T'u NT OF H =.LTH
:,�.. t.
T �131Ji�iY tilt �LVVlRU.`,C.`TL Fi - - •�
t1L,'1 "K ._.VICES
DESIGN DATA SHEET - -SEPARATE SE.:aGE .DID ?O -AL SYSTEM
FILE NO
tt1�
Owner �1� Address�VtiY
/v
Located
at. (Street). Sec. 9
Block 3 --2-1 S
Lot %
(Indicate neares t, cross street)...,
Municipality V: ` ..atershed
SOIL, PERCOLATION TEST DATA REQUIRED TO BE SU'E'iI! �rD t;'ITH aPPLICITIOV
Hole
A,
Number
CLOCK TIME PiRCOL.aTION
PERCOLATION
Run
Elapse Dept'. to Pater
Srater Level
No.
Time From, Ground Surface
in Inches
Soil Rate
Star - 'Stop 'Min. Start Stop
Drop in
Min/in.drop
Inches Inches
Inches
i
gII3V 9,5z ZZ.
:7,,
v
2.
Z 1.0 '-Odr
3
�:Q .o - t '. 3 �F4 1� Co
5
It to
-
�Z�l 1z, o 3 t `
t7
Pt
`_ z
3.
4
T.41-
a\G 5
_zi l
4 ka II'. 3 �-.6
iR
0 1A
5
Notes:
1) Tests to be repeated at sa ^e depth until approxi -atelv equal soil rates are ob-
tained at each percolation test hole. all data to be submitted. for review.
2) Depth mea;,_,rem.ents to be made from too of hole.
18't
24'"
3 Or:
36"
42
48"
5 4"
6 0"
66"
Y, S
-72:*
a°U'l+1\16111. CLtii ,
DES' f} HEL2"
7 8 `t
8 4"
INDICATE LEVEL AT ;,,N-, ICH GROUND WATER IS E \COUP +TEi��D
Iti`:DICATE LEVEL TO WHICH G %ATER LEVEL ,RISES AFTER BEING ENCOUNT- ED
TESTS �SADE .BY. j. �lu.�- O.. I C. Date '6w, . i Z
Soil Rate Used lio•'�O Mir /1" Drop S.:D. Ls= �a °rovid°.d
of NEW Y
No. of 8edroo -s 3 Septic Tank Ca _ci �y �jo �P� `. �.•kF oR� pe
Absorption Area .Provided Byl'&QO L.F.x2`" ? ar h9 n Other
;
Name 1 (1 � Q �_ Sim ate; re
terp,,,,
Addres Q ..1Z �M Yc S Fn !�o. 421a��a�`��
k;: ..
,w�I �'uFESSiON" I .
PUTS` ?aL%I COUNTY ,DEPART,IENT OF HEALTH
Soil Rate Approved Sq. Ft, /Gala
Checked bye_
Date
0 0 0 sz,
1:1 Tlt
it
N
c:-
1 � v � i 1tt ; n.,,/
,f.(APPROVE0
MAY 9 1972
NO TRUCKS,MACHINERY,.BUILDING MATERIALS NOR EXCAVATED EARTH SHALL BE pi OF "fix
IN THE SEWAGE DISPOSAL AREA. CONSTRUCTION OF THE .SYSTEM IS .MAN 14TY P?-
0f
BE IN ACCORDANCE WITH THESE PLANS ANY REVISIONS THERETO AND THE
AY—MC AC THE PERMIT ISSUING GOVERNMENTAL AGENCY
RULES AND MLUU�- - . IWRQKMW taW
M ' AS BUILT PLAN:
Ci
I
-- i, 71
ei
1.
SEPARATE. SEWERAGE j`•SYSTEM
OWNER:
LOCATION:
V,9/z-c/(7) !BLK. —L(
CONTRACTOR:.
DOLPH ROTFELD AsibocIATES'
512 MAMARONECK AVENUE,WHIf- E PLAINS