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HomeMy WebLinkAbout3285DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73. -2 -8 BOX 26 03285 3Ij3I�b 1PURMANCOONSDEFARTNMMrOF1 LU= DteYea dllritr�eaeaaAlal �d Seat keo. Calaab N.Y. low late ► 0 Ltia Tewa � ► OSefe Fee Enclosed Amnn,nf- �■it =rM i lit A1m 1,nl ri-7 Z An F® SecdM O* Dept* �vaiss DO C. Neanher d Deirr�e. Dodge Plow G P D � PC® NddlutMa Is Required Whoa F® As oesoploted . Seipeab Sweeep Syatam M Nast of + Z' GO. Sspdc Teak ••a l '(3. 1-1 KI To be eeeto4.a -by -77 't Address Wear Se*!IF. P Sop* Fteog Adbaee an ✓P "Onfi, Sop* DRIM by I � +� • —Address MGM! 1 represent that 1 am wholly and completely, responsible for the design and location of the proposed systern(s); 1) that the separate sow di sal stem above dtoaibed will be constructed as shown M the approved amendment there to and In accordance with the standards, ruhs a rpu ns o rutnern County Department of HaaRh, and that on comple6on.thereof a "Certificate of Construction Complianee" satisfactory to the Commissioner of Meoahwill M submttte0 to the Department. and a written eWrMtN will M furnisMd ten owner, his futcessers, o► aWgfls by the builder. that said builder will Glace in pod .operat{p condition My (Tart of told sewage disposal system during the perked of two ! s knmedlately, following the date of the low. on= of the approval ed the CertNkate of Construction Compliance of the original system any Ir thereto; 2) that the dr {IMO well described above WO M IenteO as eliawtt Me►sw(�ten appr(ev�N� genre and that wire wNl will be Instal p Nh ndards. rules and rMY aeons of ten Putnam Dab a4 6 -1 �� 4.lV 5 reed P.E. R.A. �— Address. P� ? Lieennse No APPROVED FOR CONSTRUCTION: This approval expires two yaws from the date Issued unless constructk►n df ten building has been undertaken and is revocable for cause or may be amandad or modified when considered necessary by ten Commissioner of NNah. Any change or alteration of construction feOYNea as permit. s Approved for disposal of domestic domestic sanitary Mweed: a� private water supply only. Rev. 0/88 rC�% my �"l ` -� TRIG Na si ..Olb Oft Apo' WV. .0/88 Rte: and is r afterat1611 of coAstruction L/ e DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION. TO CO1JT12UCZ'`A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Town Village City Tax Grid Number A-" 1r� t'DZ-It- `�'j o WELL OWNER Name Mailing Address aftfvate' �-!F>0 x v O Public USE OF WELL 1 - primary 2- secondary 8-kESIDENTIAL D BUSINESS D INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT � gpm /# PEOPLE SERVED , /EST. OF DAILY USAGE 600 Sal 13 REPLACE EXISTING SUPPLY O TEST /OBSERVATION L1 ADDITIONAL SUPPLY EMW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING . WELL TYPE C2UfILLED DRIVEN []DUG []GRAVEL POTHER IS WELL SITE SUBJECT TO FLOODING? YES `'� NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:�� Lot No. t O WATER WELL CONTRACTOR: Name i o'er, Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL/CITY DISTANCE TO -PROPERT-Y-:FROM -. NE.A- RES.T..- WATER. MAIN :. -..:_ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) (signs 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 clear. 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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from.such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate. surface.or groundwater. Date of Issue: -,, - 19 Date of Expiration 19_ __L_ Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller m F-• 0 Cl 1 I r� �1, 1 n I •. UI r 1' I) Ln 1✓ U O rr r rP (U ti � r• 'rr ] (i +[ T Imo. r. �' 11 !11 I J c� t f; tr) ID W 1--+ N H N 1— t o U I (] CJ o 0 0 0 - F1-rt—— 0 �r rt. u rt r1 (, In S O ,•T to u u J In ( {1 N j 1. d o In I-•. G i-1 i mri I,1 rl• 1�• jii r• (i1' Oi t d to 1 Il r (D h• ti g I. I_... 1,:3 Cl fir• Iii D r f: 1r1 I-h Fi (II f) 11 C.i, ill 1 t I. 5: 1 1 e- rnnn �1h�(7b�;CGL! �ti 10t:9, 17 t � m it Mmrn rh O 111 In I(, l H r•�d )y (� to :7 ip,r(7 1 ' h n I 1 �I1 m O S. ., I I••• In 1-" t• 1 -' D{ pl 1p N N N ,� in �n a� P `� ; n ro `(1 ni ), � 1. � rn 71 � n h \t4 rt' c7:t� I-t• � U rn u) 11 N Y !n O H� `ui cri 11 1 �� U b 0 rr (n ly I11 (l- in p ;, u (U rr 1l ill 1 -' r r I h, to u1 r {, r "• iu , O o !-� n N z rr �• �; F'• 1 (D O (In ( 0) (Ii r m re, F (((((rtttttrll111l In m (D (� /1i rt ly (t I� I '• (j CJ 1 I� ;(D V (�,� �, n In iii {• 1,Ir 11 1 Ns. 1ri 't1 I t,) o In r1 ( a Ifl. n 111 171 (b I --' ,.,. ,... — jh (J. • D+ I'• 1 lu 11) h u q 13 j j �il , PI c] �IU '] ID I J In 'U I s 1 V. 1 n in rf 11't' 111 hj : J j� Sri rr rll I `I ri, �U i1n r 1 n I� C) cn t, lu I� ,z� s i DT' <t 'l. I-' Ip 1 t 1r1 j rCl, n ,r1 (t;. �� iti to �fi in (y `j `r?• III I t�. n (� r ,r1 IfI h1 j i (n rr C) lIJ rl N to 1�• �, ,] J: h � 11 p [3, f rt I '• rn (~ r1 to IJ (ri rj T� Iv cl [n v i 01 C) to II' 1'I j�• l-, 1,1 .- t r C1 111 1 Ili: Ic1 I', 1 I II rri in in �u I rr f�• H r.' Ci I UI Ui rl rr .1, I 1t n � I'1 I' u O 1-11 1}0 :j ID y r — r 11' t'r 1.1 ly iT1 I (I U 1, I � �I I ` ,21 rn ui (1 d �t �(1 t.. ,i4•♦ }s f�. i (tj 1" Ij y �r7 h (r FJ +J [_1 d hi i� [n (� Q' ' A hj n� i� LI F�3 I-11 In 1-i I n In uo 171 ' ID rd n In crl 1 17 In O 1 ( " (1 (,I r� r7r (I1 : r (� (U i] ID ill ly ,(7l(� ti Icy f1 �G (D rC) in -!. ny NI i � i7 IT 1 ) { (!1 r7 In 1.1 ly iT1 I (I U 1, I � �I I ` ,21 rn ui (1 d �t �(1 t.. ,i4•♦ }s f�. i (tj 1" Ij y �r7 h (r FJ +J [_1 d hi i� [n (� Q' ' A hj n� i� LI F�3 I-11 In 1-i I n In uo PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -.CWNTTIO'FFICE-'-B7LJ=ING ":CARIYEL,- "N.'-Y:- DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. -Owner y,-,) Address Located ­at*(Street�F L' - 1,,k 11gQ Block U -Lot, .22 -.f- A/0 indicate nearest cross sTree T>'( Municipality, III,-fp V4, Ile Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Ran Eiapse "Depth to Va er ater TFv_e7_ No. Time From Ground Surface in Inches Soil Rate Start-Stop Min. Start Stop Drop in-- Min./in drop Inches Inches Inches 3 17 /7 4 5 A4- 2 Notes: 1) Tests to be repeated at same depth until approximatel� equal soil rates are obtained at each percolation test hole. All data to e submitted for review. 2) . Depth measurements to be made fromtop of hole. 3:2- �30 2- 2 X05 J 34! 3 340 o 3 17 /7 4 5 A4- 2 Notes: 1) Tests to be repeated at same depth until approximatel� equal soil rates are obtained at each percolation test hole. All data to e submitted for review. 2) . Depth measurements to be made fromtop of hole. 3:2- �30 2- 34! 3 17 /7 4 5 A4- 2 Notes: 1) Tests to be repeated at same depth until approximatel� equal soil rates are obtained at each percolation test hole. All data to e submitted for review. 2) . Depth measurements to be made fromtop of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION 'OF SOILS — ENCOUNTERM IN TEST HOLES. _. — DEPTH G.L. �OCJSOII 1�0�5 6„ 12" Jn 190ow 24" C',ITT?rn 30" 36" fl 42" 48" ! 5411 60" i 66" n C �" 7/ 7211 78" c 84" INDICATE LEVEL AT =H GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO H WATER LEVEL RISES AFTER BEING ENCOUNTERED .Vat DESIGN Soil Rate Used 3) -/Min/1 "Drop: S.D. Usable Area Provided vJ EZ' 9CC�3 No. of Bedrooms `f Septic Tank Capacity 1_6 Gals. Absorption Area Prided By_gt�L.F.x24" 2j A,;,� :,. 71 Clij [K Address SEAL �_;: 'L ;, J� iN THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: 'mss.., Ed e° Soil Rate Approved Sq. Ft /Gal.. Checked by Date x .,. ._ P_UTNAM COUNTY DEPARTMENT OF HEALTH. :— !- __biv` is o bf Envi�ro AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: is represent that I am an officer or employee of the corporation and am authorized to act for (Name of Corporation) having offices at r Whose officers are: President: Name and Address Vice- President: �1�% W ly� R. 0� 4�/ 911� _....: _ _. (Name' ind Addres. ) � Secretary: (Name and Address) Treasurer: (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 sub equent acts relating thereto. Sworn to before me this day Signed: of 196 Title: �� 6Q_ Notary Public Corpurate..Seal o 91 n.- T 'A" . .. _ .. .... � _ .: a r� "i' r tog •••••u •+;�i�tl6l��jl�Y►batassoo'.r .l �.yia s'�fr`:aoJAOtY�- lIGaZC:S:rL:�.' t x .,. ._ P_UTNAM COUNTY DEPARTMENT OF HEALTH. :— !- __biv` is o bf Envi�ro AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: is represent that I am an officer or employee of the corporation and am authorized to act for (Name of Corporation) having offices at r Whose officers are: President: Name and Address Vice- President: �1�% W ly� R. 0� 4�/ 911� _....: _ _. (Name' ind Addres. ) � Secretary: (Name and Address) Treasurer: (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 sub equent acts relating thereto. Sworn to before me this day Signed: of 196 Title: �� 6Q_ Notary Public Corpurate..Seal o 91 n.- PiJTP1ikbbUPI d Y bbA11TBdiENTVFHEALTW w R6v,.-'. .3-186 "Divislon o -L'nvlromm "T C V.V-• CATE OF-0 NL )N[PXMNCF. FOR ,,:SEWAGE DISPO VAI CER r. -4--- 777�' ...... ...... ...... —�7 IAMW ii, Taxi, � ni qiLlIle vAet # e 10 A P milfbifi6d C.) Mdil-g Address Date. e ZN�A se*.t6sevrerage System built Co S C 6 Isting of Gkll6nt�i Tank and L AdkW 9Pet®r Supply: Public Supply !n SS A Addiiii L ors Private Supply DrIDed by oi, 1; ied? Building I ion ,CA ce NU�M66 of S 41,666 ? Ok) Other. Re4illirez!kents A t ?age tially� gi,Ab��rn rk, (,copies i��7ic6ord&nce,-witn.tne standards' '� rules'."and r one n�ll` .,,an. the, of which are i I , , A ' figiied by the Putnam County apartment Of Hea1tA / gn "R .A. Date Atldress E. 5 1 canoe No R a -h certify,that, the syatem(s) as listed serving the; above premses were ag An y, ,Og4on occupying ' tIY talcs mk� h n9co!"ry 1 t , any un"n i ary dondltidns . 'UCh U509C hhibna n"IV avid volt 0 -p,n gy:"�.beComes V and tfie 8gPfbV a! � Of private we Suih,4jirovmls are . subjeltt to. m6dif icaiuon:or change ud -,N ga Ith .V i A ii- n or ch I Is nec"Wry, Date )0;- -----T it is TNAM COUYN DEPARTMENT OF HEALTH Owner or Purchaser of Building Building Constructed by M IC.,uoiz __E9� Location - Street Municipality r_I�Q r-( r,, Building Type (oZ I; t J0 `'ee ' o Block Lot 1VVI ti Subdivision . lc Subdivision Lot # GUARANTEE 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- per iod -of_ -two . years immediately following the--date of. appi oval � of the .• " "Certificate `o"f'�onstruction "'Compliance" 'fob "tie �etvagE disa-syst-ert; 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 occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the deterniination of the Director of the Division of Environmental Health Services of the Putnam County Department of Health as to whether or not the failure o the - system to operate was caused by the willful or negligent. act of the occupant thE building utilizing the system. Da is day of A-cl 1qq Signature Title Ge eral Contractor (Owner) - Signature VO,yo�D�i Corporation Name (if Corp.) (0 1�) cx v Address T rev. 9/85 mk Corporation Name (i.f Corp.) awn NI Addre s c 1 �0�%'`f AA1R11T TTT/lLT T1TT1/1TlT WALL lr Vl'1r L�l tVly L�rvAl Office Use Only .0 DEPARTMENT OF HEALTH =i3v�so =© Lnv -rt rrcental - ��'W Y�4 PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADDRESS: TOWNIVILORWICHY TAX GRIO NUMBER: WELL LOCATION. 10 Miller Ro — ` A � I �� WELL OWNER NAME:' . AODRE S: �7 Devon Development L/ ATE ❑ PUBLIC USE OF WELL 1- primary 2 - secondary RESIDENTIAL . O PUBLIC SUPPLY O AIR /COND. /HEAT PUMP. ❑ ABANDONED . BUSINESS O FARM 0 TEST /OBSERVATION ❑OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL 0 STAND -BY p MOUNT OF USE YIELD SOUGHT -.- gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING CY, NEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 700 ft. STATIC WATER LEVEL ADD __ft. DATE MEASURED 3/2 DRILLING EQUIPMENT d ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ® OPEN END CASING. ❑ OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH 166- fL MATERIALS: [ STEEL O PLASTIC O OTHER CASING DETAILS LENGTH.BELOW GRADE 164 fL JOINTS: O WELDED &THREADED OOTHER DIAMETER 6 in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE XI OTHER WEIGHT PER FOOT lb-/ft. DRIVE SHOE. ❑ YES D =OLINB:OYES ❑ NO SCREEN DETAILS DIAMETER (in). SLOT SIZE LENGTH (1t) DEPTH TO SCREEN (ft) DEVELOPED? _. ,._...._. - .__.__.�..::.._ ...._ - _ E]- YES- , ©-N(I� . r.. SECOND - -• -. .. _ _ .. ..._ - --• GRAVEL PACK O YES ❑ NO GRAVEL DIAMETER SIZE OF PACK in. TOP DEPTH ft. BOTTOM DEFni it. ','If detailed um in WELL YIELD TEST p P 9 METHOD: ❑ PUMPED = 1 tests were done is in- • COMPRESSED AIR , formation attached? • BAILED O OTHER ; ❑ YES ❑ NO ELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- 'n9 Well Dia- neter FORMATION DESCRIPTION CODE. ft fl WELL DE it. DURATION hr. min. DRAWOOWN It. YIELD gym. Land face Overburden 76 700 Limestone 700 6+ WATEa O CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE Inipl ],aj�rnl CAPACITY 250 GAL. WELL DRILLER NAME OA Norman Andergpp�"�� L ADDRESStGrr>L7URE , w - 152 Barger St Putnam Valle NY 10 PUMP INFORMATION � TYPE SLiI.mer,, CAPACITY Grundfos DEPTH MAKER �g2 �. MODEL VOLTAGE HP 2 1j u- Yorktown Medical Laborator Y. Inc. LAB # 321 Kear Street Date Taken: 4 -18 -90 Time: 'IPM York -town Height Y OS _ _ s,_N. 1 98 Date Re' d: 4-18-90 Time • 1 OPM �A...:_.. - rt w _ Da � Rev9rted: - 245 2800�a == _ _. z.�.,�.,.$ ro �: �.. Colected9. B. ron.in Director: Albert H. Padovani M. T. (ASCP) PO /Client # Referred By: T Sampling Site: Water tank tap Norman Anderson, Inc 10 Millee Rd. Putnam Vlw, NY Box 152, Barger St Putnam Vly, NY 10579 L I REPORT ON THE QUALITY OF WATER Phone 9. "INORG CS. m L -MICROBIOLOGICAL 100mL Alkalinity Standard Plate Count _ Chloride _ (CFU /1 ML) _ Copper Not Detergents, MBAS Membrane Filtration Method Hardness, Calcium f Hardness, Total Total Coliform I _ _ Iron Lead _1,/ Fecal Coliform — ---- — Manganese Fecal Streptococcus _ Mercury _ Nitrogen, Ammonia Most Probable Number Method Nitrogen, Nitrate _ Nitrogen, Nitrite — Total Coliform. Phosphate, Total Fecal Coliform Silver -- Sodium — Fecal Streptococcus Sulfide _ a Presence%Abserise 'lPA)` Sulfite Zinc Total Coliform PHYSICAL MISCELLANEOUS KEY FOR TERMINOLOGY — PH (S.U.) — Color (Units) Conductance (uhms /c) Odor (TON) — Turbidity (NTU) P A CFU = Colony Forming Units LT = G1T'• = Less Than GT = 1 = Greater Than NA = Not Applicable SA = See Attached TNTC = Too Numerous To Count REMARKS COMMENTS For Lab Use (For Lab Use) SAMPLE TYPE: (Check One). /Potable Non- potable OUTGOING: (Check Each) HNO — HC13 .� H2SO4 _ NaOH ZnOAc Na2S203 Other: INCOMING: (Check Each) sT 1L AS _ ` G1T'• 4Y' /LE 200C GT 200C _ PH LE 2 _ pH GE 12 — Other: THESE RESULTS INDICATE THAT THE WATER SAMPLE (PAS)) (WAS NOT) (NA) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE , YORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NUT) SC MEET THE SATISFACTORY CHEMICAL QUALI STANDARDS OF THE NEW YORK STATE DRINK- ING WATER CODES, FOR T A ETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. 7 /87(Rvsd1 /90)RWE A-11. -- 4- r �.i nor r:,ry _m_ ,P Director -