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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