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HomeMy WebLinkAbout3284DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73. -2 -7 BOX 26 a 0%11 tip f .cr r. :r .4 m16 11 I" Y I -PUTNAM COUNTY DEPARTMENT OYftAITH Milo t" Health iSeMceit"4�N-Y 10 8 b, AD. Permit I! =l S, �AL Sir ATE, OF.�CONSTRUCTION COMPLIANCE F SEWAGE-DISP6S YS .0*, �Z&i: C-5 - lAwsted Tea Map Lot 6A N' i.-Lot Formerly SnbdiAiloill,�11 Owner/aPp"C" N8*0 7, Z16 -Peiinit'hiied, 05:) E5 IV 14014 Addxisi ay, tpp ate, '6=2wa kr Separate: :bjAt:by Consisting di' 177, '5V �03illdnSeptkTeak and water SUPPIY- :PubH6 Supply From, Address or:— Prl ate Supply Diffled by_=W7-1-4':�A Address &OrnnKy- A Building Type H Erosion Control Been Completed? ­P Number of Bedrooms Hit Gsi� Grinder Been Installed? Other Reqolreq�ents ki, , 'certify that the'syst (a) as listed-,pe ivi�4 -the.'. above premises -, were constructed.'esslential;y as shown on lans.,of the, completed work copies sm. a of •whiih,are attached),.,and in accordance With ti kula.z,,afidi'r��Iiiioni, in'ac6drrdi",npCe4 wei sled. An, and the permit iiiued by the c Iitnam county Department Of He'aith . q by P.E. - �iA Date License No Engineer C �\� T/ _ P SYSTEM' A' ddress Any par take such action as may be necessary 0 the correction: of &nV.4ns&nit&ry son, occupying premises served by_", i , , , .0 pqW% sanitary *sewer becomes tinj from such:ul0gp.! Approve} separate shall ibea conditions reiul Dmeffiul! And void at soon is a appro'vil -thi*Wate 'water: supply shall a -46ia when a public water supply becomes available. Such , approvals wo avalli6i and the - of 0,spRMenup �n . , . _ subject to modification or change when, lK the judgment of the :Cornmis0pnffL: evocation. modification or change. Is necessary. qf Health, such,r Date WELL LOCATION WLLL kjVr1rLL11U" rinrVAl Office Use Only DEPARTMENT OF HEALTH O #q�nui- ronmenY_al. Health -Se ices . _ PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADDRESS: wNlVl 1 1 Y' TAX GRto NUMBER: TIM I WELL OWNER NAME nooRESS: O core \ i` - (,l � �j-t -� p P6IVATE ❑ PUBLIC USE OF WELL 1- primary 2 - secondary 'ti RESIDENT)AL ❑ PUBLIC SUPPLY -O- AIR /COND.JHEAT PUMP O ABANDONED O BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY p MOUNT OF USE YIELD SOUGHT - gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE —gal. REASON FOR DRILLING *O,NEW'SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH n ,�_ ft. STATIC WATER LEVEL d5� ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT. ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. .OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH + : ++ ft. MATERIALS: %S STEEL ❑ PLASTIC O OTHER LENGTH.BELOW GRADE 1 3 r"I ft. JOINTS: ❑;WELDED ISTHREADED ❑ OTHER DIAMETER __'�" in. SEAL: IRCEMENT GROUT O BENTONITE OOTHER WEIGHT PER FOOT —. lb,: /ft DRIVE SHOE ONO UNEA: OYES ❑ NO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH.TO SCREEN (ft) . DEVELOPED? FIRSI SECOIVO -HtitSRS` " ._ GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE DIAMETER OF PACK in. 70P DEPTH ft. BOTT061 DEPTH It. WELL YIELD TEST I It detailed pumping METHOD: ❑ PUMPED tests were done is in- • COMPRESSED AIR r formation attached? • BAILED ❑ OTHER i ❑ YES O NO It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACE water Bear- ing well . D'a- (meter 'FORMATION DESCRIPTION poE. It. ft WELL DEPTH It, DURATION hr. min. DRAWOOWN It. YIELD gpm. Surface T-j 3 - av r 'e WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES ❑ NO ANALYSIS ATTACHED? ❑ YES ❑ NO STORAGE TANK: TYPE CAPACITY, GAL. wE �1 Ph �o� AOORE ) k4o '` Wk t►'\. PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE HP PU TNAM COUNTY DEPAXIMENT OF HEALTH DIVISION OF ENVIRO'k*=AL HEALTH SERVICES .siC. r .. ^�C �-. n � .z -t� . ..� : <_ ..w. t - � �5 [ >cr am.: �P�. +A "� A•�-.-r ... !1 .T:•.Sr ei��•. --v ^ v n .. ti .. :¢� JY .1 . ..—r v � f . � r <�r" _YA�� sr}+s.�x. �n-r Owner or Purchaser of Building Building Constructed by MIS 2,,0 Location - Street 19- Sect4eft- Block Lot 4U rs i r.J(4 0L �U Subdivision Name'`-- Municipality Subdivision Lot # --Fzrr,-���� Building Type GUARAN= 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 r .- _..._. : r=ais = made•k°- G -1C-il SjSti?. eX^,ept t:a= e €;�iie =o operate- Jroper:.:..is 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 Environinental 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 19_& Signature W �L A� %("- �JI/C►2tODK C4✓�l ess 1�4, �6 W *,/ mk Title raw. +�ius��try� r - A4Li_ _ .i Oj, ,VbkV44',')A Yorktown Medical Laboratory, Inc. -- �- 321 Kear Street Date Taken: 12/7/88 Yorktown Heig-hts,.N. Y. 10598 _ _Date R.c' d : 12 Director: Albert H. Padovani M. T. (ASCP) Fmi STEVE ADAMS PLUMBING & HEATING P.O. Box 459, INLAND RD. CARMEL,NY. 10512 1 L .J LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC NON- METALS (mg /L) _ Acidity Alkalinity _ Chloride Detergents, MBAS Hardness, Total _ Nitrogen, Ammonia Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite METALS (mg /L) Time: 12; 30pm -Time: _ 7 Collected By: zm arney Referred By: Sample Location: hose Bibb rn A? k¢ Devon Deyelopment__;7_eekski11Ho11oW Rd Putnam Valley, NY. 10579, 0 Phone # 225 -0 09 Phone # — Sample Type: Repeat Test? (check one) MICROBIOLOGICAL (CPU /100mL) GENERAL BACTERIA _ Standard Plate Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform Fecal Coliform _ Fecal Streptococcus MOST PROBABLE NUMBER TECHNIQUE —.Copper _ Iron _ Total Coliform Index Lead p;&nrg e:sse- . -C'd1`i.i,.o " "rm�IiiA� _ Mercury 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 (>) TNTC = Too Numerous To Count CON = Confluent ( =TNTC) NR = Non - reactive Potable Non-potable STP INF STP EFF Other: Sample Status: (check each) OutgoirL& _ HNO,; _ HCl _ H2SO4 _ NaO11 ZnOAc _ Na2S203 Other: LE 4 °C _ GT 4 °C _ pH LE 2 _ pH GE 9 _ pH GE 12 Other: REMARKS /COMMENTS (For Lab Use) I,ELAP #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 EET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE KING WATER CODES, FOR THE PARAMETERS.TESTED, AT THE TIME OF COLLECTION. Lx/ C �� /,GCr ' Y '_IleZ �� A-7—, 2 /86(Rvsd7 /87)RWE Albert H. Padovani, M.T. (.ASCP), Director . r V r/ 7 FEq r, S--m LIS' =E''=' C:1 V77 by T. `C�t C.v�l ._c J_W�jw CR SuJDIT%1SicN L :T Dam= oz piac =r=at 2:1 �,Fr LG=. - WIDT A C_DF'"' -i C_ Nam Lr=i scii r_c` st' d_ St —=_ br-LL in, e cce =ter t :z Z3 f -Gm STJS arm_ e_ a_ S=- c t -r'ti 5 -- - /000 1,2' G_ u: 90° ben^. -, c_-- ncuL_ W1_:,i1 10 Z_ c- c50 bend 2- P:ct =C =�_- CX L D;sta cc 4. U; t nC_ C= z G= L C__ cf `� '":'_ aC- - -Cta^1c 1/106 i p - _L/32 C i 20 r 8. _ can a iC:,z_. vr c Size of c avif 3/4 L Pig e-Es- ,o T •SE c_Stc T2. C-var= i C-N tank II � '._TlD a =s- '/ c. ^_ =_ _C t n 1Gc= `SiCi- L_•C C'rc."O ( ( 6. 0.7cl ° w_- - --- 1✓`v Lc�l `'? Ems `--_ '_ I I E TiaL =� GTN Ir z7 C-Ycie I I r7. ECUSZ- r-.—=- V. Tvr - Lvn c1 -„s f- C. C._' nc 18" d_ 5. - = =cam era - - --c We--L a=-- cza2_Le- b. cir:'c5 C c. , Cc= is f "�'i W1`/ ins CL iC:i _- G_ E__Zf CC:! ?ns SACnes < '!" in 1 e_ C_— =11'1 C.�" : ? -S �' ! .J'� cC.G^.r' ___ ^_C L.v aWaV MORM��� Ii M1 ��nj 7 `7— 7- !F:- { ARTMIM OF HFALTH., �, " . PUTNAM COUNTY DEP Division dzi H ..,N.Y. 10.5n wee[ fo Pam Yde`Pee�It M' 60, 7R CONMI 1*PEL0WFqR,SEWAGZ DISPOSWSYSTEM 1 01 7 - --------- -- T Subdivision N­ # 'Map E:.."W;d­. Let. --- T. time. L Renewal_ O 2AA .. ._­ . , I 013,1111ber/Applicaut Nule— -Ve ge—A D ate of Previous Approval 16�Malling Add. &V T ZG n 610= C-0 UJAW Town Zip Ac Building gyps �Lt Area : k. I . _8:1. ., Fill Section Only Deptti Volume Number offledreouts Design" How G P D e0f_90 PCHD Notification is Required Wbon-Fill Is c6d0le A Separate Sewerage System to colm'd$t of Gallon Septic Task one] 166 lid rr .94. Aa41177 -To be constructed by Address Water SUppb': Address Poksuppl* Fio- _____Address or: Priv'ite Sqpply, Drilled-l!y Other Req*ements- I represent, that I am wholly and,.complet above described will be constructed as s6i County Department of an�6L-iha be submitted to the Department, and i place in good operating condition any. ante of the approval of the Certificate will be located as shown on the ap0oved County Department of H411ih. Date _X., . I /_ .ON- ' ,"wile design and location* i",ap6roved amendment there to ,'I ;.Cartif , Ice , to , of m guarantee, will.be furniihii the F.40d sewage disposal. system dur ni6ru'etio"n' Complij`qce of the orig djhat saidwell.tWil be Installed in igned Aaaress APPROVED FOR CONSTRUCTION: Thisappoo4al revocable'for cause or_may be amended or modified requires "w permit. Approved for disposal of Rev. 1/87 Data. ofthe proposed System($); 1) that the-Siparabio sewage disposal system nd in-accordance with tlioe"stinciirdso ►ulesand regulations of No Putnam Co nkr6it ion � 61jipliahice" � sit isfactory to the Commissioner of Healthwill owner, his . kjcc"rs. heirs I ' or asiijns.by- thebuilder. that said builder will ng the period of two (2.), years immedia Y-following theitato of the lssu- I , he I system or arty repairs thereto iq�y: the,,ain'daid UIV 4j��ns ��,of •: the Putnam e<drffloclwell clescr Itoed above P.E. R.A. (xp" date issued unless construction ofvKe 66jiding has.been undertaken and is ire s two years" f rom t " when . considered necessary'- by the' Commissioner, of Health. Any Change or alteration of construction domestic sanitary. sewage; and /or, private water supply, orw- By me ., ia Dlvlebri N or Znvl0fG=6iW Adilffisi;AAcec, c6aiiI.Nevi 0512 to MP OVIC co cnON PER?#gr, FOR SEWAGE 'DISPOSAL ST AN 4O.''vine 'bQ T­ Mi. T Rqii. Owner APPIk�n! Name Date of V101fe:A Add,M,Aet V. � K, 4' R LA F, 11 Lot Avert" Pin th d vokini 7 Number of Bedrooms Design WIN, G P D P ­421 40 i System _00P To be constructed by ' Ti �'i b . Address, PMMWW��Vcvag !bM WSW SopPb P" PAfi;� - 7, '7- M , on ✓ pdyaws :j otbjr , ftoga6m S 'that the "rai' ijip"'i6lif, _jr�; - o I robrosent '.that. I am wholly and G� d!sigj�ar" a P! op�o! Sy I - disposal system a stem(s! . , sewage above. doi�ribid' will tie-lc6nstruc S_shiowii -in.acp0rdancp.with the "StaL ndilids. rules and egul-ations of ..!he -Flutnam County - bopaiiment . of- �iei'ih t'and tha t Y-to. 'r , r ,!�n',,coTplletlon *�(- Ci)ristrijctloh.'c4impiiii�ie--:- sal�!!actor the Comriiiiiioniic of,Healthwill !here J�,�, . - . _ __ , I— . Department,; and a `written guarantee will be furnished the owner;' s suc s "kr, be r S4 brnitted .to the cessor Sor ass4ns'by the builGdr, that sajd�'buildi► will place AhL'i6od'operating, Condition any part of Said ,sewage disposal �i'ystim6 uri t is i"441ateiy" 16116WO4 1hil-dita, ofthe issu- ance 'k� pariod"o of alpproiiii. of ,,!hio� qpft!i 41ginivsystem joi. rq t 'the drilled wiivaisciliiiami:;'above :once Mi� will iii, 10�cite'd'. r it ig'gi;u a ions �,"�OT in 1 Putnam 7 nc the-?st t � • County VI Date v , R.A. p:, Address _45-1 License No APPROVED' FOR CONSTRUCTION: This 'approval 'expo es two " f r, date issued unless construction ` , . the building has been undertaken and is years­ F(�M,.thc , I r, ­ �d "' � - . hj.. revocable for caug 0 may be"a_mended,,ov'm stied When cons!dore "h*CoSsa!yr-by'1 comrillssi6ne 6f kiai6. Any change or 'of construction I - �r_ L ­ed ', , "j, _ , . 1. . - construction requires a n ermit. .,A r� �y�of r. isposal-.O dom0f�c,_sanitary,:,siwpj _d '— ' — -L I" Ohl N Jlr� 10! POY t R6v. t/87 Date T - wi DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512.(914).225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Mt t4rP, ROAD Town/Village/City Tax Grid Number f"UT14AAA VAL L4 - it lt- 'l9 WELL OWNER Name Mailing Address DA �7►Af�,Ei" W6. APT 2Fv VVWL it 40WA0 - ivP..�nWW A%&W5 )QPrivate tai, 0 Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ® BUSINESS ® INDUSTRIAL OPUBLIC SUPPLY QAIR /COND /HEAT PUMP 0 FARM 0 TEST /OBSERVATION O INSTITUTIONAL ❑ STAND -BY 0ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT cJ gpm /# PEOPLE SERVED /EST. OF DAILY USAGE &G0U gal REASON FOR DRILLING NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ® TEST /OBSERVATION ❑REPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE 14JDRILLED DRIVEN "DUG ®GRAVEL C]OTHER IS WELL SITE SUBJECT TO FLOODING? YES X_NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: HiAt4rk,10 FIDC;V� yG- Jot l Z Lot No. J WATER WELL CONTRACTOR: Name �'� ,�. Address IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME- OF.PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED []ON REAR OF THIS APPLICATION ON EP E HEFT C_R JUKE i l9� ;�Awx (date) (s gnature) 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'. Pump the well until the water is cl.ear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue: 19 G5 Date of Expi ion: 19 ermit ssu In — g icia White copy: H.D. File Permit is Non- Transferrable Yellow copy: Building Inspector Pink Copy: Owner - PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �EUIMINT, CKI MML, 1V� DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner oWoi Mftoevlartr WC., Address AF ± 2c, DvW2oK- Yog4_�mjvt j ! et &t+Ts Located at ( Street 4dicate l�i�- RO�l7 . Sec. &-L Block Lot nearest cross street) Municipality. FOINJAM VAIN j Watershed PEP_KSktLt, �40U,60/ C-Wr_ SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole . .. _ , Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse Deptti to Water. Water Level. No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start.. Stop Drop in, Min. /in drop Inches Inches Inches �.. 2 5 � .M1- .•+u.i..�...y. .mw � _ w) t . +i ..-.4 �xa�u:sm .n y..e•. .wvn +wm. .'NT ...vt -e.. ..�.......... ...�. ..... �O .r...� ..1� �..�_ alb•, -��•� . -�,o� ���- -. _`� .�`,7 ��:-- .�,.::.�.�.. 2 3- It ;50 -e.-'M Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION CRIPTION, _Q ' SOTLS._ '� gC_QI:]M1 RED..IQ...TEST DEPTH HOLE NO.. ( HOLE NO. HOLE NO. G.L. fDP5,M, P-00T5 6„ « 42" 4$" _ n 54" +► 6o" +F 66" 78�� u _ 84" n t 02 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED._ iPL vAi£+ ° LE�FEis40-14-a- CH •WArTE, R- LEVEL - RISES - .AFTER,-BEING� -. NCOTJNTERED- -n \E'2 TESTS MADE. BY T, DAL ( Date tc> 84 DESIGN Soil Rate Used 8-l0 Min/1 "Drop: S.D. Usable Area Provided�''� No. of Bedrooms 4 Septic Tank Capacity. 12.5CO Gals. Type MA500R i Absorption Area' Prodded By949 L.F.x24" 5b" ch. 7' Ceap DP.Ait: Name 7. MlclfrNeL. nAL:f Signature r Address BoX 1tt 3 SEAL 014EE.lo -7 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Cal. Checked by to PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .. - ._..__. .iw -T.w'! -1y.� n-..r .._ w5.-F:'1...- .a•�aya::_:- T.a.Y4t v:�-M' -TK.� v .. .. -� ... ..f�>..y.•+�- .3..La- K%U.a.._.. -. ... ... ... Date .S �2 /010? Re: Property of Located at (T) Sec Subdivision of J' U ion Z Block II Lot zs� Subdv. Lot # 1-0 Filed Map # Z 7�P Date �� IZ /97 Gentlemen: This letter is to authorize A;/GJ)e;;�re A, 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 super- vis..e'., the .constructi.on...of_.said 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, im9w- A174*40 , S ' gn e d ���� �. W ��/✓Y)'�di Ly Owner of Property i� P.E., R.A. #r� Address' Telephone 1,14 /- Z 6 QUE -1210 0G eVM1110lt,� Address /foe O dMQ, Av .412 io,4 -7®a--1Xv #&-a #7f 4 own qj� LEIS Telephone t�'}gh'2•..�is�'F nLit?x�'�y14yt�� T ,....�,..�a..'s.... � K����'4',.c .��`i•�` a S 'Sq�r.��`'•�' Y.�, � ,e. �i.va 3,3,E v:-r � _}!'���,,(,�� f �t. "n .� a. _ i ���^ �i� y��� .�`�rwi PUTNAM COUNTY DEPARTMENT OF HEALTH .:.• DIaT1�> LOil ':O €,= Enli!1TOnmental—Mea1.C'I` Se' VlC$S: �` =,:cs ` =: :v .= - tr T=•c _. AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PE14IT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health. In the matter of application for: - - - AZ/ represent that I am as officer or. employee of the corporation and am authorized to act for � � llmo - Al/ //vxt -)1% AL11'a'a)Di , ot ' de'l (Name of Corporation) n having offices at �� ewe)1n1,1091!�;. &6H 1s/Y / ry c Whose officers are,: _AA / /� n �IPresident: 4� 0II'Sh ll. �Rdodolld/V ��//JJ (Name and Address) (� Vice - President: Ink /�'�2�' 1061i�%�i/'1 aAl y k// / P .• (Name` and Address)' Secretary: - -- /�' 1i ©U/� df/�iil//��,i'�%�9'� I& 2C OW-46Z, &dJ%'W'3� (Name and Address) ' Treasurer: /� /� �D��►G1/ `✓� i 12,f�/'� (Name and Address) / 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 A day Signed: of 1999- Title: f'` F a l' J' Notary Publyr RYLSAIDEL Notary Public, State of New Yak No. 4743051 Qualified in vt,estchester cou Term Expires March 30. 19MI Corporate Seal 8/84 APPEMIX B PrJrNi %.M CCTj- - DEP_ARM= OF HEALTH - DIVISION OF ENVIRONME?M HEALTH SERVICES INIDI4=UAL WATER SUPPLY & SUBS[TRFACE S" -.�, DISFC AL SYSTEMS PZVIFTri SHEET - CONSTRDCSION PF;' MST 'r_ _._`..�:: is -r?,'; •,v`a,. �wa-n a:-- -r..:.us: •.h.Y.:.,. .. ^DATE Ra..'FV_,1LL G (.lane of Cwre-r) — (SEreet- Lccrticn) C.mL`_FN7rS YES I NO I DCaMITS Permit Applicaticn Corporate Resoluticn Plans - Three sets s/s Engineers Autnorizaticn Design Data Sheet (DCS) S EDlSICN Deep Hole L,Og Perc °ze Consistent Perc Res lt (3) Fill - I z=�-- � Perc Hole Deptn Ca �T I I l L 2 `: encn prov_G - / '7 7 r—_ui rr.._ a aliel to contours LL SYSTLIVS k av'rarrier 1 ft. fiX notes ne:e ze . 100 vr. flood . reservoir, etc. . trigall /call. ns - Two sets c>.-' pe_*-ni t; F:v� letter Re;ruest IC✓ _ zAL Lc�al Sub 'ii vi sign StJoi" vi Sion P -ccrova'_ C^_ec:ced Ex- acrrcval SSDS Pd-:. Lots C'_?ec: Wetland (TCw -n /DEC Psr-n.li t R & D) Data Cn DDS Plans & Permit Sare REQL'17ED DETA = 1 c CN PL: NS _cea,e Sy=t--n Plan - (::ortz ar_.^w) Sewage Sys t-EM =ircraul?c P ~ofi = a�;_�; I - G F' Fill Profile &l D � Tens_cns - Vol=ne D cf J ;Trench /Call err; Pimp pi = ce �._ls .Seotic Tank - Size, Det-ii -j Well Detail, Se= �ice Line i over Ccnstructicn Notes (grinder rat?) perc and .- deep. res• _] _ _ - -- , Twc _F cot toitours Eli s E i ng & P_ cccs ed Driveaav & Slopes Cut - Footina/Gutter,Curtain Drains (discharge OW Perc & Deeo Holes La tea Represzntative or primery and expansicn Mcpansion Psea; shcwn; gravity flaw, su.fi . size Ii Pimped Pit & D Box Shcw-n & Detail, House - No . of Bedroans Wells & SSDS's Win 200 ft. of r cpcsed Syst-c PrcprLy MF'tes & Bounds House Setback Necessary (Tight lot) House Sever - 1 /4" /ft. 4110; Tyce pipe No Bends; Max. Bends 45° w /cleai out SEPARP.TION DISTANCES SPECIF= CN PLsti Fields 10' to P.L., Driveway, large T:-e✓_ :,Top of f 20' to Foundation Walls 100' to Well; 2001 in D.L.O.D, 150' Pits 100' to Stream, Watercourse, Laka Unc. e_r 15' to Drains - Curtain, Leader, Footing 351to catch hasin,storndrain,uioed watercct 10' to Water Line (pits -201) 50' inta=rdttent drainage course Sentic Manks 10' from Foundation; 50' to well 15' well to PL .9 t it f-, t 1.:;1.. "S PAR to Wiam Uounzy ijaparTmenc ox nea.Lth )Ivislon of Environmental Health Servio at kipproved as noted for conformance with ipplioattle Hules and Reaulations of the ?utnam County Health Department, aA. a 'Pitaer BANC FM's Z-7--I(. TtA (-I ­6 7.-- Fig I 41 5�4` i 5- to FM's Z-7--I(. TtA (-I ­6 7.-- Fig I