Loading...
HomeMy WebLinkAbout3405DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.08 -1 -51 BOX 27 rs :lmi him ,. N III i T 1,� R. 1'L 1 T I IN 03405 BRUCE R.. - TOLEY.... _ .'' y� DEPARTMENT OF HEALTH 1 Geneva Road .Brewster, New York 10509 :LORFTiAi:ARI D �T N .. wP. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 October 13, 1999 Ivor & Veronica Whitson 3 Miller Rd. Putnam Valley NY 10579 Re: Addition - Whitson- Miller Rd No Increases in Number of Bedrooms (T) Putnam Valley Tax # 73.8 -1 -51 Dear Mr. & Mrs. Whitson: I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans, bearing the approval stamp from this Department dated October 13, 1999 The addition is approved with the following conditions: 1. The total number of bedrooms must remain at Four without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be _ ' ..+�. .. .... _. . �T-..: ._...- ..— ;- .... -.. a. ^.aw... :i wY....S'__.. n-i. ..... .. u.. ...`:9 ...`. �. ..� -. -v_ .r. ..: . .....+er. .. , � N._T- .x.. �'...M..— ..-..:. ..a --.- u.. ..✓ar ...ter... -... ... _..p<.•..>y.p . 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of thelown of Putnam Valley- If you have any questions, please contact me at your convenience. Very truly yours, Michael Luke ML:kg Public Health Technician cc: BI DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Far (914) 278- 7921 PROPOSED ADDITION APPLICATION (RESIDENTIAL ONLY) to" r' "M STREET 3 *L eA /Za&a TOWN \44 t-zzl TX MAP# ZVO/L 79— VEXOaic'q NAIvE T4 osv PHONE r i PCHD # MAILING ADDRESS J Alle t CPA Public Health Director DESCRIPTION OF ADDITION Fw i� a g. �A c.6 /� ,E M ,�/ � NUMBER OF EXISTING BEDROOMS PROPOSED # OF BEDROOMS (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) *Any addition which is considered a bedroom requires formal approval of plans (Construction Permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. .r.n.r+a .... :w...fl-..e �-'TC�'+r�JS..� y.,.... ..].�: . -.,- -» .... F.e A.. .s .._..- . «�.,y.•w .. .— ...-�, v...4 .—.q -..w +. �,m..e• r ..,.JM_ «wr... �» —�{ Please submit this form and th% following to Putnam County Health Dept., 4 Geneva Rd., Brewster, NY 10509, Phone 278 -6130. 1. Certified check or money order for $100.00 2. Sketches of existing floor plan (drawn to scale, all living area including basement) * Non - professional sketches are acceptable 3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #) * Non - professional sketches are acceptable 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. 5. Copy of Cert. of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE Comments Feb 98 .ten v -- _ .. ._ tL L u. :.e1 n w�.. - i!•1 ='a� .� w9 �� +tn DEPARTMENT OF HEALTH Division . Of Environmental Health Services 4 Geneva" Road, Brewster, New York 10509 (914) 278 -6130 Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Re: Residence Tax Map 73g- I — SI Town P-, a.— n1ILU� Gentlemen: BRUCE R. FOLEY, R.S. Acting Public .Health Director According to records maintained by the.ToNvn, the above noted dwelling IS NOT in compliance with Town code and the total number of bedrooms on record is 4 This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: OTHER (Q "Ijl� Building Inspector PUTNAM COUNTY DEPARTMENT OF HEALTH L = - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORIMATION Name of Project %"?i' (,- " '� (T)(V) !' TMrr Year of Construction Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. L.�Hilly ❑Rolling L`�Steep Slope 9Gentle Slope ❑Flat 2. ❑Evidence of wetland Clow area subject to flooding odies of water ❑Drainage ditches ❑Rock outcrop ES NO 3.: Property lines. evident? _.... �, . 4. Water courses exist on, or adjacent to parcel. ❑ 5. Existing ' individual wells w rtlun 200ft of th e existing ? ❑ SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. ❑Level Gentle Slope ate6p slope B. ❑Well drained DModerately well drained ❑Somewhat poorly drained OPoorly drained r' C. Area available for SSTS. (Primary & Reserve) ❑Extremely limited ❑Somewhat limited aAdeaquate —ft x ft D. INSPECTION Date 0 3 9 f Inspector o eridence of failure ®Evidence of failure ®Evidence of seasonal failure CA M M J HOUSE i (1) Indicate location of SSTS A. Size and type of septic tank gallons Illetal OConcrete OPlastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streamstwetlands) �i SECTION E. EXISTING WATER SUPPLY CIPWS []Shared well Individual well DDrilled ® above ground 0 D g COivBENTS : REPAIRS ONLY: As Built Inspection Required: Status: As Built Submitted: As Built Inspection Done: Inspector: ,CAc,,I.r "o,-- Cjr—A— VALt-ev My t- I., - TN 7-9.. -7;? 1; 74- x VA-4e- X o/ Ydf- ckow-1144 PUTNAM CGUIM WAKNINT OF HEALTH HOUSE PLANS APPROVED FOR I A-L BEDROOM COUNT ONLY, VIR % BEDROOMS Signature & Title Date U, A /2 CoivB./7/eivErtS 46 0,AV TV ,CAc,,I.r "o,-- Cjr—A— VALt-ev My t- I., - TN 7-9.. -7;? 1; 3,yvILLER ROAD 1'voic yNU V <R o�vicH WyiToSp„/ Pi , NAM VALLEY -7- UPSTAIRS / q x MA 10 _J `Je :a 4, !, OPEN S \ V O OVLI§ ^ i' 10 BATFI( LOOM 5.9•y:9•�.. k• k ryJ t4 1'. 1 I+ 1 i ,t lr r . 1 � s 7 ` BEDROOM 17.91 /2 ^S,1 1 •& 1 /21• { �t ; •5 za '• C •i, i �ti Q 1 i f 16• &1/2 a BEDROOM a21 •s••a PUTNAtvt COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; BEDROOMS .; PST Sigrat:iie & Title Date 4 16.00" - - -. b Cr2'8 ",+J BATHROOf19: ��' 12.8.1/2'7C1Ts" CLOSET 11 i 1 PUTNAtvt COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; BEDROOMS .; PST Sigrat:iie & Title Date 8'6•X2' FOYER 10'2" 13'6" DEN V5-X LIVING ROOM I79-1/2"XI413' it'd STAIRS A &o 3'5 "X 10' POWDER ROOM 6 FAMILY ROOM I8'1-1 /2")(13'9-1/2" 2`X9'I 0" DECK F KITCHEN eA 3 MILLER ROAD, PUTNAM VALLEY OVERALL SIZE OF HOUSE: 46'21-A32'6" (EXCLUDING GARAGE) 7A—X AllqP 73. r. pf F.; GAFU GE 25-5" ij:2 I PUTNAM C.OUNTY.DEPARTMENT Oe"HEALTO HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; BEDROOMS A.'—f Z 7*,61, /99 IM F.; LOT 13 � 3 ... At - 36' 01.34 Lr a FT wo o 4 /Ng GE F e 4 SE =j- 198 31. N LOT 12 m 15 Z AREA = L0226 AC. t - m SEPf /c arSsEM /4R�A � ! w �,�E of LEr i.vG iTREA Ar LEA3r / /!o X o a. !G rr Ile wall - LOT 11 {! 669 4: deck I , i t // , 2,51111Y FRAME d ' !� DWELLING , 333 . i \C 0 Well LANDS OF HOMEOWNER'S ASSOCIATION RESERVED FOR DRAINAGE CONTROL PURPOSES n N / ---, 52. F R v. 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH ,.. Division of Environmental Health Services, Carmel, N.Y. 10512 J Enggineer Mast Provlde� 1 P.C.H.D. Permit #— Pen) 73, 3,l � TIFICATB OF CONSTRU ON COMPLLANCE FOR SEWAGE DISPOSAL SYSTEM Iota at Ta>tMap Block Lot�T: Owner/ cent Name -woo �/yeV�L1d0k ormerly �-1 Subdivision Name� fabdy. Lot # MsWng ,Address !` Zip I. Date Permit Issued Separate Sewerage System built by .0 Address p,o� Consisting of Gallon Septic Tank and 02 -y-TZwn Im VVA' Water Supply: Public Supply From Address or: ✓r Private Supply Drilled byWQ�Mj AN02115on Address 6' 0QX 654 PUT. L14V & Building Type VJ'-5 WeQVII 44., Has Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been Installed? ( OJ TAAW K.!P . Other Requirements �J I certify that the system(s)— listed serving the above premises were constructed essentially as shown on th p ns f the completed work ( copies of ahich are attached), and in accordance with the standards, rules and regulations a rdan with th 1 pan, the permit issued by the Putnam County Depa tmelnt�of He 4th. Date y / / —a-��— Certifi by p.E.� R.A. Address No. Any person occupying premises served by the above systems) shall promptly take such action as may be necessary to ure the correction of any unYnitary conditions resulting from such usage. Approval of the separate sewerage system shall become hull and void as n as a pubt': sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes avallabic Such approvals are subject to odification or change when, in the judgment of thhee C,.om,m,.isrsion'er of Healt ch revocation, modification or change Is necessary. Data �� By Title f PU NAM COUMN DEPAR24ENr OF HEALIH Owner or Purchaser of Building pe7IOrJ J) "ew PYn Building Constructed by H 1 Ut e. V-,j" Location - Street ��t�►�nn V �.e� Municipality Building Type °(02 ►1 3I Seet o Block Lot kyv\'\")� VAv6-e, Subdivision Name \Z. Subdivision Lot.# GUARAMM 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 I• .._. _.....operate for._a._.pQd of_ two years immediately following the date of approval of the �-_ �•.r °�°"-�`1:��`c:.]"'LilC'c�%�`C;f �. tRijL2 '�'isitvl7"�iiTi'iridtiGe`._:' iii °�i��"Scircz�"i'x:t��:,�'TS° 1%�stc'�it,.-'vi- �:,j�. r :_.. -- 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 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 ie 'lding utilizing the system.' Dated this Z O day of 190)1 (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk Signature Title Corporation ame (if Corp.) Address / C< Cm. t WbLL L;U1vLrLL_11U[4 mrxuru DEPARTMENT OF. HEALTH PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only /'00 WELL LOCATION STREET ADDRESS:' wNi I I TAi GRID NUMBER: 0. . t d" IL ke 'ter/ WELL OWNER NAME. I V ADDRESS: jpe 0 00 e I i @,PBIVATE USE OF WELL 1- primary 2 - secondary V4ESIDENTIAL 0 &GLIC SUPPLY ❑ AIR/COND./HEAT PUMP 0 ABANDONED 0 BUSINESS 0 FARM 0 TEST/OBSERVATION 0 OTHER (specify) 0 INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY 0 AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ❑TEST/OBSERVATTON ❑ADDITIONAL SUPPLY �fEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL. DEPTH DATA WELL DEPTH fL STATIC WATER LEVEL 91 DATE MEASURED DRILLING EQUIPMENT Q ROTARY 0 COMPRESSED AIR PERCUSSION ❑ DUG 0 WELL POINT O'CABLE. PERCUSSION ❑ OTHER (specify): WELL TYPE 0 SCREENED ❑ OPEN END CASING 0 OPEN HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH ft MATERIALS: 0�STEEL 0 PLASTIC 0 OTHER LENGTH BELOW GRADE ft. JOINTS: 0 WELDED CD-THREADED 0 OTHER DIAMETER in. SEAL: 0 CEMENT GROUT 0 BENTONITE UVHER WEIGHT PER FOOT Ib./ft. DRIVE SHOE: OYES 9416 1 LINER: OYES EINO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (it) DEPTH TO SCREEN (it) I DEVELOPED? . FIRST � ' OYES NP. A _0 GRAVEL PACK 0 YES 0 NO GRAVEL SIZE: DIAMETER OF PACK - In. TOP DEPTH -ft. BOTTOM OEM It. WELL YIELD TEST -If detailed pumping -[WELL METHOD: 0 PUMPED 1 tests were done is in- 9,C6PRESSED AJR formation attached? ❑ BAILED ❑ OTHER 0 YES 0 NO If more detailed formation descriptions or sieve analyses LOG are available, please attach. DEPTH FaCM SURFACE 1watir Bear- ing Well Dia- M ter Ine FORMA71ON DESCRIPTION coof ft it WELL DEPTH it, DURATION hr, min. DRAWOOWN ft. YIELD 9pm. jo y WATER 0 CLEAR TEMP. QUALITY 0 CLOUDY. HARDNESS 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? o YES ONO STORAGE TANK: TYPE -"11-y-l-'rd CAPACITY GAT,. PUMP INFORMATION TYPE Ahb%q CAPACITY MAKER ar.11/41 DEPTH ! H MODEL VOLTAGE ME HP WELL DRILLER NAME DATE ADORES Aloylo"all 4s'idiff(TURE M_ AA/- 0 Adr - 162Z7 111-10i r / LAB # Yorktown Medical Laboratory, Inc. Date Takeo 321-K�e _ r - �.� Ti ct: a Ti Me Date Reported: 6 -25 -91 .'. (914) 245 -2800. Collected By: H. We.ine&man Director: Albert H. Padovani M. T (ASCP) PO /Client # 77- Referred By: r Sampling Site: Lot #12 Mitt et Rd..".' PO Box Howand UJeine�eman �unt.in - Ridge Subd�.vtid.i -on i • Yokktown Heght4, NY 10598 Put- am V.�.2u Kitchen Tde Phone (U4—) 132_62MO 1 L J (For Lab Use) REPORT ON THE UALITY OF WATER +' SAMPLE TYPE: I(Cheek.One) INORGANICS (mg /L) MICROBIOLOGICAL Alkalinity Standard Plate Count ® Chloride _ (CFU /100 ML) Copper 200C Detergents, MBAS LE 2 Hardness, Calcium Coliform & Related Organisms ® Hardness, Total Iron Circle Method • MF PN P/A ®_ Lead ® Manganese ✓Total Coliform — Mercury Nitrogen, Ammonia - Fecal Coliform — - Nitrogen, Nitrate — Fecal Streptococcus Nitrogen, Nitrite E. Coli Phosphate, Total -- Silver —_ Sulfate LT = G = Less Than Sulfide GT = > = Greater Than Sulfite NA = Not Applicable Zinc SA = See Attachment(s) — TNTC = Too Numerous To Count PHYSICAL MISCELLANEOUS P = Present (Positive) N = Not Present (Negative), PH (S.U.) # = Also done because To- _ Color (Units) tal Coliform Positive _ Conductance (uhms /c) Odor (TON) Turbidity (NTU) REMARKS COMMENTS (Lab Use __VNtable Non- potable OUTGOING: (Check Each) :r • H2SO4 NaOH ZnOAc �. Na2S2O3 o.. Other: (Check Each) �LE 40C GT 4 /1E 200C —_ GT 200C _. PH LE 2 PH GE 12 — Other: NYS FLAP #10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NA) OF A SATISFACTORY. SANITARY QUALITY ACCORDING- TO YORK STATE PUBLIC DRMING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) ZA)C MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE DRINK- ING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. -``Sy^t`f',i .i`s ''i. �, s � M �" `" T ' l V1�IM [0001f1'l�AZ1ld1'ftOF)6tEAL1'8 � � (CATS D �P��llti OP COlQUAl7Cg 8-@s � IT t C' w: - �. -'` �r ,�, r� � { '-..'� rti .� ra ', �c - `s 3Q .n, Ci + w • i or, ��Y [ ;h kTaJ• o '-': v � .� `M '. r[ "Y sr *^ r v4 - t. � q : 2 a`t, 'l �u - 5 ins r. ^+. A � a r 3 r � � �' ��� xrirll �� o � w s v i T S t • j�ok �:t h 31 �nsFL is o �.. ',Fee -Encloseda� * z I+10w G P D PCs IWmcal)M V �e4d�sri Whae'PI� V Oa�pMOed Al p a S7 M a�it`d Sstptle Twks OwI�OMd � � � s •t.,�� � BP � � i � �ti +2� t P [ �MLhllas � 4 , t , � } �'< F t � "` '� L � a {� e « a� ^ ,� vu, rS „� r - � s �: rt 1ro�� i x•� "g �� � � fiiyl` .� � tir k... � ,1~A , 4'tt r � a�, � ^ ,� k,,' � � r ` Y c,D am wholl ine tompNti n nsipla fwStM dss andibeation of . tM" e y IY spo r q pr�possd systim s) 1 'that tM .apara aw di x('. stem rill ea'oonstruetaA as shown on 21 a app►owd amandnialt tM►� to and b acco� dance with M standird; ruNS a r u nf'o JIM rlt of MMRh and th t on campNtbn thwaof a$sCsxtifiata ,of Coastrudbn;Complianp' YtidSaw.10 to tM Conimitabea _'Of MMlthwlll apaflnlMl alld a wrtttat',puarantia will OdrfurnishW tM owni► his NKaao► ;'`MNS w awgns-ey, "tM euilda►. thit .mid guile w will tM'� oaWltbn anY'.pat Ot sa10 fawa�a$dlspotal�ayRsnl Curia/ t'ha�pwioA of tw0�(2) yaan`' IaNly foibwhq thiOaN of tM Ipu ` .� ogt:ofktM?Ci►tflkatd o! Co"$trWbn7Con plNna olit4M ginalsystwn'er any npaNS,tMr o 2) t' ! tM d►ilhd wdll Aowiad 46ow ` t ahoryrl on tM app►owd plan and that asb wNl wtll a Installi0 M accords wlt tM fta u iM rMu a�ii%ni of ` tM Putnam y SgMA E R.A h Adds liesnM No CONSTAUCT,ION Thi app(Oaral axpMaf;lwp yaan`f►om thi data isfuad 11nNU �ona�►uctbn of; buildirq Ms. biiii W dwtalc, &.nd is r o► rosy Oa inlarld�d' of ng011fitl wMn_eonsWaioO =naeiw►y by tM Commitfionw of ;MpAh "Any `eh�nOa or aKwatbn of eomtfuctbn wmR: pW*Md /w %!100111114 domsstk tanRwy awwpi. and prWata wat aup�ly' only` — rt _.�._.�a.�. -..- - ....�.7' cop ®WR O"r° Nin PUTNAM COUNTY DEPARTMENT OF HEALTH Date To: From: 1-5 Subject: 0 --7 1.2 CT C,6 9(/ z FINAL SiT?E L'�`rE�' -rV Cate �(/ r"3` --• �� Tt? a OR SiG'I L.1l' r + rz .��L X+ c... W3 ...+..•C.'..6risraM'L^.'•��s. . R.. � . . 5= •irr' DISi -CSr_r, P I{ cJ5 Z� lCL._ -t' as r amroved DlGns b. f_11 se --L-, c,l - Date o= piac_=rrL-_nt �vG.D�Fi 2:1, LC-rR tivw'F� C_ rTat==_l sci_ rct S`i>✓c a_ S`_^ne, bras: , e=., cry t =r t:tF-,1 15' f =CR SL,c Za-- e_ i n0 ft- f_cr va_ar CCUr= =!:Yell I _ I S`r� = DT I 4` b. S_:;L? c tz--, Lk i:•C -= i C. 1 ��' IILs ' : �1 iC TLr_ __CII band I C_e:- :_ ^_cLt W? ='L^ 1 f = Gr ��° e. r 1 ; TF _rj -?'TCy Bizx 11 t7r SGT— L. G =•l eZ =Tra LSCIl �• WG_ar L. -C �� _.._ I I CX f_ j_ -C.0 `ICN E K .. Dis wa to r.Lar-1 i r ca C. - --C'1 cC:cC - =n I G 1 f I 'p - i /32 b. Rccn a!1c.:E—�- = r e:c- -ansicr_, 5O- 1u . Dec•L'? C-f C �s7� in t an-Enl _121 ML—L, � I 1_. Pig — .._ -Y j' �� l :w`T I.Jti`�.� ►. T_t!. � _ .LC v -c- r.�: ..v. r+..rn .. = -- .... x j _c � ..w —.. +v 1. size cr E:*=— 2. A? ate, v_s�1 !'- MP�c1°_ t0 C Cn cv 6 . Crc1e W-* —_ by EG_1 ta . rr • a�� t I C, t e a_ Ecus=_ Ic =- r_r a*= -rrcve_- v . Gv _ Plans r de^ b. rz. Di ta CeI.: I I I I I I C. 18° at,=a Cade- I I I cr L r= Wa a_ E✓Yes >✓rcz r _-; c-=cttEa ( I I L,. _E.! ? v back= i 1 1 U I _ C. -' L`1Cc5 f "c': With liL_Ce of b= I G_ �'t =i11 II3�__sl ccnt lrls Stcnes < E_ a i,I c=; = install--A acccrdi^_c to c?_n f . . C•= � dry_ CcL =? 1 Frcre & dir. to I I C. T r` -C c =, -r o E'rCL_ilc C. -.-- G-- c -.c_Ce atvav t -� ��S �'_ I h- S. czctac�4cn CrC-, 1C=` Cn S 7 C)CES C= t. =r t. an John M. Simmons, M.D. HEALTH DEPARMCNT- Lj.Lv.L0.LvX4 OF rjL14% mvL1%vwA14JL4ftU HEALTH SERVICES Deputy Commissioner of Health FIELD ACTIVITY REPORT Sheet of INSPECTION NAME 1:2 Orig. Routine Orig. Complain Z Orig. Request No. Street m 11m No Canpliance Complaint Camp MAILING ADDRESS Final P.O. Box Post Office Zip Group Illness Construction TELEPHONE Reinsjxaction PERSON IN CHARGE* Field, Sampling Only OR INTERVIEWED Field Conference Name and Title Other DATE 21/7110 TYPE FACILITY TIME ARRIVED 12 /0 TIME LEFT Explain FINDINGS.: 1� INSPECTOR: TELEPHONE: Signature and Title PERSON IN CHARGE OR I acknowledge this Field Activity.Report. SIGNATURE: 6/86 TITLE: G / /�° � r e`�'�' °ms's."-- : +�.rff: ...aa�. .:rr :,,. ..�sa�zy >.�. ��:. � ... .. � e� ® / /� - w.a+.o:1. hy`�.s' -.°' ::.�:;.. ..:..:: :c, v+- .:fin': �. a d ��� �� ol9.?J � b � � � ®� o �� �� � �o� ��y � �4 � �s ���o/ � g9 Ate' � - � - -_�_. _ ._ ... _ .. - - - - - _- - J _. � -.. _.e -. - r w i- -- •• � — � c. v . v.- a �� e_. y., .5:. .f— .. - y — .., J X2 'OK e }'^r z v -a.c� z.. ,J- ..re.. i -. ��F+ '.:_ _� -.. o-..:w�:�,.,.t .;��.v.�..., av'4•:�i a+: �::.. an- .��'t -�:.a r.M :�-n:.o.ii •.:.. i'wu.^r i -_� ... :c. � w DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT- Sheet of INSPECTION NAME 49P7'71 - - - - Orig. Routine MAILING ADDRESS P.O. Box Post Office. Zip Code PERSON IN CHARGE OR INTERVIEWED Name and Title 1/5R �//-- � ' "Al I X d W" FINDINGS: TYPE FACILITY 1 ` "-r% Orig. Complain Orig. Request Canpliance Canplaint Carp _ Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other Explain u v AM / -/' < ACS• GT' i Opp- INSPECTOR: TELEPHONE: ��s® 104r ' el Signature and Title �, (P dap PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: ®� 24l aYr. 'rstu�l9i9:abeunCYN�rip e4eA Af%*6 AZW PUTNAM C06NTY DEPARTMENT OF HEALTH C of .3ir4il� i af i^•riE " S err < p^ G�:.s♦ a W...e Sxi oxyrrr vc. h . C laesTw AFFIDAVIT — CORPORATE OWNER APPLICATION FOR PEEL4IT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the 1111Milt--3r m atter of application for: ?el 6&1-e t� 6 J 6A) I, represent that I am an officer or employee of the corporation and am authorized to act for ,06�7T�Di� (Name of Corporation) j d //( d(JJV having off'ces at / //" %l?' 6U�� Whose officers are: President: /7/('r Vice = President: Secretary: (Name and Address)' A � & -g&41 L) A/W, (Name and Address) Treasurer: , Qty / �—Z Ya (Name and Address) and that I am and will b corporation with respect thereto. Sworn to before me this of 0LC:(L NJ d 70e-S' A� / e individually responsible for any and all acts of, the to the approval requested and all subsequent acts relating 12> day Signed: ) %Qx'1-j 199,V Title: V, r a , Notary Public MAX L SAIDEL Xft Public. State of New York Oft 9820275 in Waftester County OMMI Im Ex Im Nov. 30, 1989 8/84 Corporate' 'Sea'l DEPARTMENT OF HEALTH Division of Environmental Health Services 'TY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 �•iL � f 1 � � �9T I.\ Jr � _ .. . .� .._ ...�::. :•.:v ,. �.w4L Y�r�,i r : 5 \'Gl S � .• ,1 � � <R, PCHD PERMIT #/ !// R� WELL LOCATION. Street Address TownVillage C ty Tax Grid Number i e-r' -RoaA --?U+ yarn val !!�i a. - I I 81 WELL OWNER Name Mailing Address a can �fPrivate 1 ✓Dn 1 JE �,,t,�-- t a G, Over-loa� Corr mans f 4}r, O Public USE OF WELL, 1 - primary 2- secondary RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ❑ ABANDONED 0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify 13 INDUSTRIAL O INSTITUTIONAL 0 STAND -BY Q AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED ? /EST. OF DAILY USAGE 600 gal REASON FOR DRILLING ato SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING AAuJ z WELL TYPE DRILLED 13DRIVEN ODUG GRAVEL O OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: u n Lot No. / Z WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES c /PTO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY 'i w _._. bUTk4CE-TO' RRG nRTZ ,FRUrrYvcA REST- ' li`iG:..,�.>... LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION �SEP TE HE r={= 13 (date) / (signature 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 b the Putnam County Health Department. �_�,® Date of Issue: f� 19 Date of Expiration: 19� ermit ssuing ffi a White copy: H.D. File Permit is Non - Transferrable Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller APPENDIX B PUMNLAM CCUNrY DE2.WD= OF HEALTH - DIVISION OF ENVIRCNMR?ML HEALTH SERVICES n1DIVIDUAL WAXER SUPPLY & SUEOURFACE SEM=- DISPOSAL SYSTEM-5 PM IT DATE REVITDIM� BY: (Name of Cwn —er) (St=eet Lccaticri) YES f NO DOCUMM Permit ApplicationGr Corporate Resoluticn / : e- . o� Plans - Three sets S/ Engineers Authorization Design Data Sheet (ME) --Tu-B-�DIVT-SICN Deep Role L,--g parc -e Res- (3) Fill Consistent Pero Res 1 11 - ---4— Perc Hole Depth cd el, I r-F I L House Plans Two sets q:�j Vari a�T �-Recues- Legal S•7 Ddiivis,icn ubdivision A-carcvai C1er c; ac- approval SSMS Ad-�i. Lots Checkcad Wetla.pid (Tcw-n/!)EC PS=-,2Lt-.R & D) Data C-n DDS Plans, & Pe---,Liit-- Sa7ze L7-- trendh provides- I REQUIRED DETATICS CN P=ANS System Plan - (north ar- =w ft. rra i. I Se-wage System Hyc-raLfl- ic Prof .1 - Grave vv Flow le-1 to contours Fill= "rile & Dimenslons - VbD-Mle D o d, 100% em,. ;Tran6n/Galler k y; PLzp piL. C F= SYS= cl1aVbarrier 10 ft. fill 11 notes rlelq sue. depth gauges 100 yr. flood el-ev_.-,' 200 ft. reservoir, etc. 150 ft. trigall/gall-. 4 - Size, U11M Size, F Vt�ll Well Detail, Service L-*L,-le iff. . over Cc n s t.rq&t 14 a t. ��s n,-;e,, r , r'-7.t e) 4- D -s- e ign Data: pert and deep res-,L'---s Two-Foot Contours Existing & Proposed Drive-Ray & Slopes Cut Footina Zer /Gat Drains (discharge CK) Pere & Deep Holes Located Representative of primary and e-=nsion Expansion A-re--;shcw-n;gravitv flcw,suff. size If Pt wed Pit & D Box SIicm & Detailed House - No. of Be roans Wells & SSDS's w/in 200 ft. of Proposed Systan Pro.ae-rty Metes & Bounds House Setback Necessary (Tight lot) House Seqer - 1/4 " /ft. 4110; Ty ;e pipe f No Bends; Max. Bends 450 w/cleanout SEPARATION DISTANLICES SPECIFIED CIN PLAN Fields 10' to P. L. I Drive-Nay, Large Trees, Top Of fi. 201 to Foundation Wails 100'.to Well; 2001 in D.L.O.D, 150' pits Z 1001 to Stream, Watercourse, lake (inc. erx: 151 to Drains - Curtain, Leader, Footing 35,to catch basin,stL:ormdrain,ciped waterccur. 10, to Water Line (pits-201) 50' intemnittent drainage course Septic Tanks 10' fran Foundation; 501 to w-e-11 15' Well to PL 9 • •' • � •• 1' 1� d• '1 ; �• Mme. DESIGN DATA SHEET- SUBSUFACE SBgAGE DISPOSAL SYSTEM FILE NO. ' . � .. r -',r :::.a�: , :, v;..a.. �, •. ,rn�,,. •.a+ -.a s. � .... �.r •w. •..J.'.••.:.. � -'i_.y ti� v' .. .. n ..v-.....r.c.. •..:;•..�- .:,:.:• :.^{,,; Owner e1i D51 Address M TZSOVl Located at (Street) ,1 S L Block Lot (indicate nearest cross street) Municipality l t Watershed SOIL Pg2U0LATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking ,(14, Date of Percolation Test 0 HOLE NUMBER Qom' TIME PERCOLATION PERCC A ON , Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min/In Drop, Inches Inches Inches ^} Q10 2 9OS- q35 .17 i 3 10•)0 uo . 1-7 4 5' 3D ) �� . —. -aws �.•�._�. o I� U� ! V // yam... . a. v .. wA �,c�.N... ��" ate.. ...�� .. q �++ vu�. Q w .. .. ... 7"w V 2 7 T 1 2 3 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained it�each percolation test hole. All data to* be submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE. SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. - .. _ -.y. . .o . ,•.ice. , r^ :.uP L -- .a. a,,. _...r - .�....'. .--.. .... .. w ;,.d•: ,r .. a•.: a•• ..p. .. „w ..>..: ... - .•. a.....- _:.�':. G.L. 1 ° 16P-A4 ICJJ: AT 4' 2° n 3° 4° 5 ° �! GL 61 if 7.0 r� 9° .10 ° 11° 12° 13° 14° 'GRCUviiTA i5 -r3' 00CJ Mic _..... _..._ ..,. _ ...... . __ . ti .._.. _ INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING MMUNTERED DEEP HOLE OBSERVATIONS MADE BY: / DATE: DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided. 10406 No. of Bedrooms - Septic Tank Capacity gals. Type � of n,E� / Absorption Area Provided By 8y L.F. x 24 �° width trench �� - �I (�o� F Other ! �+✓ "' S~ � o — � Name / ` Signature' Address SEAL cas�6e a�ESSios+a THIS SPACE FOR USE BY HEALTH DEPAR'TMEN'T` ONLY: Soil Rate Approved sq.ft /gal. Checked by Date I-AM, T"__ -woo ova "I 7"S Mon. E0 IF C, An V1 all 12 7tt WAS& Sol too 1 M%," No -Wfy- M. 01, MA P i AMA-11 All" 1 fi ,nam County Department Of li"i dk iivision of Enoironn9ntal Ilealth SerVIOVI� SS noted for conformance with Ipplioiblo gUles and Regulations CpLt�ty Health Department.' va..►.+»w► 3 Title UatA am