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HomeMy WebLinkAbout3281DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73. -2 -4 BOX 26 03281 - :.'•-' "� r PUTNAM COUNTY DEPARTMENT OI? HEALTH Division of Environmental Health Seivlces, Carmel, N. 10512 j IEngineer Must Provide , I 1, P.C:HD PeiWtH I a GERM OF;CONSTRUCTION: COMPLIANCE.FOR SEWAGE DISPOSAL SYSTEM '". Located at i Tom. Bloc si Lot, t OwnerLapplicGat Name l ',r Formerly _ Subdivision Nsme L bdv Lot # MaWng Ad ss, ; �'G{ !�%l�Ttl.�pl� �Ob»/Y1E1AtS - 'ZLip �8 Date Permit lssaedUGI Z �5 Separate Seweeage Syatem butlt'by i? `fir Address A•MC�' Comsis of i 3. —7 S% L 1 ) �� �'� O I ° IG ' 1U/ . ling Gallon Septic Tank Water Supply: Public Supply From Address ors ✓ Pdyate Supply Drilled by Address AMOn 7K : h► Buildldg Type M ` Has Erosiou`Comtrol Been Completed? Number of Bedrooms Has Garbage:Grinder.Been Installed? -i Other Requirements �� nl '?i2�1 ►.� . s,•�, b } I certify that the systemj(s) as listed serving the alcove premise§ sere constructed'eswntially as shown on a lans.of the completed'wo,i.'( copies of which are attached) and,ih accordance "'with •the- etandards,:.rplas and requlations,.in accord a with Udp and the permit issued by the Putnam County Department(Of- Health - _ .. tie- ► 6 I jc� �l Date —= Certified by Address / License No. Any person oeeupying premises sewed by'the abovs`system(s) shall promptly take Such action as may bs neeessar 6 secure ihevorreetlon of any unsanitary conditions resuRjng from such usage Approval of; the separate sewsragsYsyitsm shop, become null and void as soon as a pub,% sanitary »wer,bacomet available antl th6,approval`of thef'p►Ivate wale► suDp�Y shall become -null and,.void when a;public wale► supply.'bicomas availabN. Such approvals are subject to modiflrJtion or change:kwhen,'in the judgment :of the Commissioner of "*a th. su %eevocatloh, 'modlfteation or change Is necessary. Date PU`I'NAM COUNTY DEPARTMENT OF HEBLTH �D SSON. OF ENVIRORRO TAL iiFAL 1I SyIC%F _. Owner or Purchaser of Building Building Constructed by (Yn u.4�12oa.n Location - Street Section's Block Lo Subdivision Na Municipality Subdivision Lot (0 Building Type GUARAI<t= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the loca workmanship, material, construction and drainage of the sewage disposal s, serving the above described property, and that it has been constructed as she the approved plan or approved amendment thereto, and in accordance witl standards, rules and regulations of the Putnam County Department of Health hereby guarantee to the owner, his successors, heirs or assigns, to place in operating condition any part of said system constructed by me which fait operate for a period of two years immediately following the date of approval o: tlCe ficate.: ,. :Cor�6tructaon- Coinpl-iance" f -or- the sewage disposl'- Osten, :e.- repairs made by me to such system, except where the failure to operate proper., caused by' the willful or negligent act of the occupant of the building util the system. The undersigned further agrees to accept as conclusive the detenninati the Director of the Division of Environinental. Health Services of the Putnam G Department of Health as to whether or not the failure of the system to operat caused by the willful or negligent act of the occupant of the building util, the system. CQ Dated this L day of /t/ 19 0 Signature Address rev. 9/85 mk Tittle 06 aC C Address �DLY;aw //' T) WZLJLA UurirLr'ILUM. REPO L DEPARTMENT OF HEALTH Division . Of Environmental Health Services Office Use Only WELL LOCATION STREET ADORE S; TOWN/ VILLAC41CI I TAiGRIO NU 861: tur 0 1 1211L,19- _jQ0_r WELL OWNER NAME: ADDRESS: _�QNVO- rJ C-D I' r rJ I a C1 PBIVATE ❑ PUBLIC USE OF.WELL 1- primary 2 - secondary `t& RESIDENTIAL 0 PUBLIC SUPPLY ❑ In 1HP* PUMP 0 ABANDONED 0 BUSINESS 0 FARM 0 T ' ESTIOBSERVATION 0 OTHER (specify) ❑ INDUSTRIAL 0 INSTITUTIONAL 13 STAND-BY ❑ AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING '**rSNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION ERVATION o REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft.1 STATIC WATER LEVEL ft. AO�T DATE MEASURED DRILLING EQUIPMENT 0 ROTARY COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE 0 SCREENED 0 OPEN END CASING. ***'ROPEN HOLE IN BEDROCK 0 OTHER CASING TOTAL LENGTH fL MATERIALS: **IS STEEL 0 PLASTIC 0 OTHER GRADE ft. JOINTS: OWELDED 'b--THREADED OOTHER DETAILS _LENGTH.BELOW DIAMETER (D —in. SEAL: 0 CEMENT GROUT 0 BENTONITE **WTHER WEIGHT PER FOOT —lb./ft. DRIVE SHOENYES ONO I LINER: OYES ONO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH To SCREEN . (ft) DEVELOPED? FIRST 0 YES ONO SECOND HOURS GAVEL PACK 11 'YES ❑ NO SIZE. DIAMETER OF PACK in. TOP DEPTH - ft. BOTTOM DEPTH - It. WELL YIELD TEST If detailed pumping METHOD: 0 PUMPED 1 tests were done is in-. 1 ❑ COMPRESSED AIR formation attached? 0 8AILE0 ❑ OTHER 0 YES 0 NO It more detailed formation descriptions or sieve analyses HELL LOG Are available, please attach. DEPTH FROM SURFACE water Bear. ing Well Oi4- meter FORMATION DESCRIPTION Coe. ft. WELL DEPTH tl DURATION hr. min. ORAWCOWN It. Y YJ E L 0. – Land Surface — 7cf 19 al'i TV T WATER 0 CLEAR 'TEMP. W T 8 QUALITY 0 CLOUDY HARDNESS A QUALITY U TY 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? ❑ YES 0 NO rMA STORAGE TANK: TYPE CAPACITY GAL. A UMP INFORMATION UM P PUMP 11 TY PE MO EL CAPACITY DEPTH VOLTAGE HIP WELL DRILLER VAME • OAJ�) SIG RE ;V� C. T. MICAAE1, DALY, P. E. Comultiny Enyince-t 91f l628 -0 BOX 243 • SHENOROCK, NEW YORK 10587 CA - --'s 6(pn TO-ML- �Gdiza C4) (S 4)(1?0) toy, G Co �p 61'F>M T>aT- le- 15- ---------- FF-O%f %`P� 14G, z o I -G� C3.14 gSTo 95 Yorktown Medical Laboratory Inc LAB " - 321 Kear Street Date Taken: - Yorktown Heights, N. Y. 10598 Date Rc'.d : 1_ - (914)245-3203_ _ .. -s ..e =..� o.rts -d_�.- ' .i�T..... -. .� n •1.1 4•t ....Y' •s .- •T+y- �+•4- ..vk: �%�.��..:.+. �••.. -n. +# Z�irectoi Albert H. 1�ad�ovani M. T. (ASCP) Collected By . Referred By: r T- -1 Sample Location: STEVE ADAMS PLUMBING 8c HEATING b(?A)&A b 2, /P.I alb m 6 P.O. BOX 459,INLAND RD. CARMEL,NY. 10512 . L Phone Phone J Repeat LABORATORY REPORT ON THE QUALITY OF WATER Test? _ INORGANIC NON- METALS (mg /L). MICROBIOLOGICAL (CFU /100mL) — Acidity _ Alkalinity Chloride _Detergents, MBAS Hardness, Total Nitrogen, Ammonia Nitrogen, Nitrate Phosphate, Total Sulfate _ Sulfide Sulfite GENERAL BACTERIA _ Standard Plate Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform Fecal Coliform _ Fecal Streptococcus- METALS (mg /L) MOST PROBABLE NUMBER TECHNIQUE _ Copper Iron _ Total Coliform Index Lead Ma,ng�aes•e___... w. -. -- Feea1 <•G,o -ifarm Ind—ex­- - _ Sodium KEY FOR TERMINOLOGY Zinc CFU = Colony Forming Units MISCELLANEOUS pH (units) Color (units) Odor (TON) Turbidity (NTU) N/A = Not Applicable LT = Less Than ( <) GT = Greater Than ( i) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non - reactive Time : .2 ,1E5-PM Time:. 104-01 ._ �• R Cam• AL-'.� Sample Type: (check one) Potable _ Non - potable STP INF STP EFF Other: Sample Status: (check each) Outgoing _ HNO3 _ HC1 H2SO4 — NaOH ZnOAc Na2S203 Other- u LE 4 °C GT 4 °C _ _ pH LE 2 _ pH GE 9 pH GE 12 Other: REMARKS /COMMENTS (For Lab Use) IELAP #10323 THESE RESULTS INDICATE THAT.THE WATER SAMPLE WAS (WASN'T) (N /A) OF 'A SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE NKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. 2 /86(Rvsd7 /87)RWE iovani, M.T. (ASCP), Director I- z� ' °L- b . FL-1 s is . -Dame L=- cf C_ r��:� ii d- 1 f =an Si)s a e - n0 ff_�:..___- Ccur_e/rYe_i nom^ �ET`C Wink s_� _ — 1, 000 =2c C. 1_n, 7T ii =u C. i" 90° hcrrc, C_- =''CtL- W_ ='Z? 10 f= C= CC 1 3 1 l CT. e c � sz T— - E! =Tc - C^ - ;.- �; C L C cw ^'-C S is i_ ECUSE c =zrc:v ' r1E_.S ' Zar b. • __ 1 ercrc V of c � =n 2 f_ 7 SLE a= rr==S. f` C_ Drcr k-'- -d__ L'1L'c5 C� -__�' _V C`C_�: =il 1 cr• C_ 1__ Di=es f - " =', W_ , _ C n to D-1 -2 rl C `-'7C C_ =_ -' _ C _ to tl _ S• -__ _ -- C-- _ - ES i =_ r" m I fij 1 ( ' I I I i rl �I ' Di S t ^_C_ nc �- _ _ _ _ ter` - _ C2 LZ G. 1-0 %— = .`: %ice =`r i � 20 �' 7. C .0 `- in t = (I h- �' ` CSR ECG; 2- C'v er--. C-N 3. DAL v.�- =i /C.- _'3I1D e =5__•T cC = == - -n i ° Tc �S C! LO C•r3Cc ES p-ma: =- __GIN Dc -T CrC1e ECUSE c =zrc:v ' r1E_.S ' Zar b. • __ 1 ercrc V of c � =n 2 f_ 7 SLE a= rr==S. f` C_ Drcr k-'- -d__ L'1L'c5 C� -__�' _V C`C_�: =il 1 cr• C_ 1__ Di=es f - " =', W_ , _ C n to D-1 -2 rl C `-'7C C_ =_ -' _ C _ to tl _ S• -__ _ -- C-- _ - ES i =_ r" m I fij 1 ( ' I I I i rl �I PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Envkonmental Health Services. Camel. N.Y. 10512 ProvWe Permit N on CERTIFICATE OF�4yp�IPIdI CON ON PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit N Co �1 J, ,- j own or e Subdivision Name 11�L� li `� Subd. Lot N Tax Map V-2 L---1 �Block�_Lot Owner /Applicant Name QC qf) "g7o�� Renewal— Revision ❑ Date of Previous Approval (�� Matllog Address : Q &— AMPS IU >,own L�7uA � Zip t can 4) Building Type F- i �� a L' Lot Area e S8 �. Fla Section Only Depth 3. 5 Volumo Number of Bedrooms Design Flow G P D 0 PCHD Notifiation is Rwphvd When FN is completed Separate Sewerage System to consist of Al2-V Galion Septic Tank and 2 76 W 9 Fr OF- -77 -14A. -Qi To be constructed by Address Water Supply: Pdbllc Supply From Address on Private Supply Drilled by --address Other Requirements I represent that I 'am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules an regulations O s u County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, 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 disposal system during the period of two (2) years I medlately following thedate of the issue ance Of the approval of the Certificate of Construction Compliance of the original system or any repairs ther ; 2) that the drilled well described above _will be located as shown on the approved plan and that sold well will be Installed in accordance with the sta ar , ule nd regu a� oil ns of the Putnam County D tit Health. Oats Signed P.E. R.A. �_ Address "f License No 8" J APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless con-Auction of the building has been undertaken" and is \ revocable for cause or may be amended or modified when considered n&-- essary by the Commissioner of Health. Any change or alteration of construction requires a ew permit. Approved for di oral of domestic nitary r�wa an �r' aterr supply only. i . '' ; � Date 1 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ' Cr'. =. t. . ;�!-;" .. x_,..�....- -Y,'.'.M '. :_. •__ s..« � .�z ie .r > . .... r1=z n:.r <,.: v' APPLICATIO_y . N TO CONSTRUCT A WATER WELL PCHD PERMIT WELL LOCATION Street Add r -ss Town Village City Tax "?U U Grid Number Name NArA Mai li g Address Private WELL OWNER O Public USE OF WELL GIESIDENTIAL OPUBLIC SUPPLY OAIR /COND /HEAT PUMP 0ABANDONED 1 - primary ® BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify 2 - secondary ® INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ® _ AMOUNT OF USE YIELD SOUGHT gpm/ # PEOPLE SERVED _e /EST . OF DAILY USAGE C-; 7 gal REASON FOR SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST/OBSERVATION DRILLING OREPLA E EXI TING SUPPLY ODEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE [2t-RILLED []DRIVEN ®DUG ®GRAVEL OTHER t IS WELL'SITE SUBJECT 'TO FLOODING? YES t/' NO i 1 IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF. SUBDIVISION: ''�Lti�i; Lot No. WATER WELL CONTRACTOR: Name Address: T IS PUBLIC WATER SUPPLY AVAILABLE T.0 SITE: YES L% NO .NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ., . _ q .�. ....a .,... ..... .....s.r y....._... _ -_ -. -. __. -... ...... r ._e �.. . ,.._... V ^__a .- a.. -..a. .... a +� r__.. ., r.__ _— ._s . r -.. --. -. r.+ r.. .{ -_ ►.. DISTANCE TO PROPERTY. FROM NEAREST WATER MAIN: LOCATION SKETCH-.& SOURCES OF CONTAMINATION PROVIDED 1�I ON REAR OF THIS APPLICATION ®'o S (date) 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. 2. 3. Date of Date of Pump the well until the water is clear. Disinfect the well in accordance with the requirements of the Putnam County Health Department.attached to this permit. Submit a Well Completion Report on a form provided by the Putnam County Health De artment. R Issue: � 19 Expiration. 19 '41W ermit ssui fficia Permit is Non - Transferrable 2/87 White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner VeDd6a -s.r-T'' Address l4 T� Located at (Street) N1, Cvr�SiL lv �. Block it Lot 9 (s (indicate nearest cross street) Municipality Watershed SOIL PERCOLATION TEST DATA RDQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking C�;L.-F 1964- Date of Percolation Test qDcrt- 4-- HOLE NUMBER Cl= TIME PERCOLATION PERCOLATION Run Elapse 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 4 E Z 3 io -o, in' 3� SO 4. 5 1 2 3 4 .5 NOTES 1. Tests to be repeated'at same depth until approximately equal soil rates are obtained at each percolation: test hole. All data to' be submitted for review. 2. Depth measurenents.to be made from top of hole. rev. 9/85 TEST PIT DATA REIQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENS IN TEST HOLES DEPTH HOLE NO. ..HOLE NO. HOLE NO. . - � a`] a - \'�•MC- Y.mke:Jr. _- - f Y.. ..y _ _ _ Go- L f( 21 u (2��r✓1 3' 5, °f 61 t3L�iG� ALv 7' 8° 9' 10' 11' 12' 13' 14' INDICA'T'E LZ1EI AT -WHICH IGROUNDRATER 1S FTNMUN'i� INDICATE LEVEL TO WHICH WATER LEVEL, RISES AFTER BEING MMUNTERED DEEP HOLE OBSERVATIONS MADE BY: �� �d�i. c_1 DATE: 0,---r 19eQ-- DESIGN soil Rate Used' Min/1" Drop: S.D. Usable Area Provided z-Z,ry No. of Bedrooms mil- Septic Tank Capacity 1 7,5V gals. Type Absorption Area Provided By L.F. x 24" width trench Other Address' 2.x}-3 SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved s4-ft /gal. Checked by Date_ PUTNAM COUNTY DEPARTMENT OF HEALTH .... .� i3TVISTOlti OF..EN` ITRON -iMEI NTTAI,.•HEALTH:.. SERV ICES> .. ' .. —.,- Date Re: Property of Located at low Z&o C d (T) c� S 2- . Block /. / Lot J Subdivision of Subdv. Lot # Filed Map # -a Date Gentlemen • CONSULTING ENGI -NEEF • P. 0. BOX 243 This letter is to authorize %"ENOROCK.N.B. I®587 a duly licensed professional engineerz_"",—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 i C. Y; I: c i Department of Health, and to sign all necessary papers on my behalf in ec supervise t -h-e system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, Si ned AG'JA Countersi % Owner of Property P.E. , R.A. , /# ' Z-G' �1/ IZL G� /C e0e2g1naxj Address T. wGIIAEE l r Address 'a'CONSULTING ENGINEER P. 0. BOX 243 SHENOROet N. r, 10581 Telephone Aoc Town APIOM &b,v ale,` Telephone 1 r PUTNAM. COUNTY DEPARTMENT OF.. HEALTH Diviiito'n-: oi,tnvironmenial"iffaiiii"te�4i'ei'-- AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAIM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: 7cnl & 12 JUd d I- VQ .0 Al 14 represent that I am an officer or employee of the corporation and am authorized to act for (Name of Corporation) having offices at 6! Dale eo P" /Y! (Oi� iq In '6" I-:-Au 0/0, X . k' -Z,0u1$V IYEL-7,14 7, ` X/, Y Whose officers are: President: 4f 12S /I q e /t/ e 12 /Y7 a AJ (Name and Address) Vice-President: MA12 g Secretary: 17V 4,/, Treasurer: A0A 6�c i, - t'_j ame and Address ame and Address 11 -L I it L I L i L i ( and that I am and will be individually responsible for any and all acts of the , corporation with respect to the approval requested and all subsequent acts relating thereto. Sworn to before me this day Signed: of 19 Title: 6 14111 Noertary Public SHERYL SAIDEL Notary PVWW, State dNWy4* ft 4743051 Qualified In We*hO" TOM EVIMS matt so, IM A/AA rutuam County Department of Health ,ision of Environmental Health Services proved as noted for conformanoe with Qicable Rules and Pegulations of the nam County Health Department.0 wa—Tu,. it ,j,H1, RIII-FS /\ND Riczi LA'.1"ON4, 01• 11:. 1', T" Z 2 9= 4' 53 -A 5 -5 , 0) CLC—A.-- Uga 77- 7— 4 P5evona.. 4 =w4x NXI, 7 rutuam County Department of Health ,ision of Environmental Health Services proved as noted for conformanoe with Qicable Rules and Pegulations of the nam County Health Department.0 wa—Tu,. it ,j,H1, RIII-FS /\ND Riczi LA'.1"ON4, 01• 11:. 1', 4, kk<, V,0 re, OF i.J Z-A T" Z 2 9= 4' 53 -A 5 -5 , 77- 4, kk<, V,0 re, OF i.J Z-A