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HomeMy WebLinkAbout3725DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.18 -1 -8 BOX 29 i� 6'J6 r IL ' -ti �Qlrl ti m. 116 111 11 1 IL I 1 ' '' TI' •. 03725 Rev.. Ito /8S ICI UI C08 CODIQg$ 29� OF d Sses6�as. x.18. ?. fl�fl8 Ia herW halt 2ff muWAMImmommm as OF htaedt 1 •'(J _ �` �'� 211s111.E. mamma ,, -rot a Tam USP JB me& jot Y ie- e5pn2l� 13- It 11 Rings Noma /Q° • Dade mi Fa®ve.o A��awval Yhft gym GYL' e!�Li &at Ana 1, 7 AG' Fm Saetla®0* LJ DagNh FeWe Napier of Behaema — FlOV c F D �� PM NefJ2edsM Is Foatdliedl Wr.M F2) IS @andleld 2apmmft SetfMP $yobs hb G O,§= SW& Ti A To ie' aiimbu eil by ' Aaa.mes wdnr 2thy� F� ea _FAseb S1111* Now by Other 2at(�ira�ahtle 1 Ia"owl that 1 am wholly and compmety responsible for the design and location of the proposed system(gt 1) that the separate sawaae dl sYStem abOVe dNRibed will be contt►uded as Shown on the approved anandment there to and In accordance with the standards, rules a regu M O Oowtty Department Of Health, and that on eanplatiowthareof a "Certificate of Construction COrnpllanee" satisfactory to the Commissioner of NeRhwiM be Vibloltted to the Oapertelent. am a - wrilterr rJormatee will be furnished the owner, his Mreosssas. he &$ or "$"a by the bunder, that sae bander win poaee in flood .OWN"* COMMON any Fitt Of sale towage dhposal sy.am durkq the period of two (2) yeas knrrledletoly following thedate Of the JIM. 1110a Of the *WOW Of ter CWtNtoate 0 Construction Cenlplierla Of the original system or any repaan th.fetoh 21 that the drilled well dose►tbed auger ws N IOOated a shesrw M /M apprOrled path and that said well will be Installed M accordiijitom the nda les and fee—u a Ors f the putnem Cewky De Mm" of tWtth. /� APPROVED FOR CONBTRUCT10N:Th1p/lIVpow1 rf.rOrMle for tonne or may be enml*a or modhfled feOYlle a new Jverm* Aimm oved fir dkwmM of P.E. ".A. 4 r ICerUa Noa y 9�� construction of the building Ras ben undertaken and is ter of Health. Any Change or ahtpatlon of cOMtllKtbn 10 vPM poky. a n/ TMb DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914). 225 -0310 _ �. v -.... . �! _�_.: s,.. �. t..�:.� _. ... •J' b.. _:,. -:'Nit • •... �. w:• - �. .. -v .. a• APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # JZ WELL LOCATION Street Address Town /Villa ty Tax Grid Number r2 e WELL OWNER N e r r 9"'y Mailin Add `° A� IV -V! h 2-- 17�°i' rivate a Ala • ❑ Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ® BUSINESS ® INDUSTRIAL ❑ PUBLIC SUP Y ❑ FARM C]INSTITUTIONAL ❑ AIR /COND /HEAT PUMP ® ABANDONED ❑ TEST /OBSERVATION ❑ OTHER (specify, O STAND -BY AMOUNT OF USE YIELD SOUGHT �� gpm /# PEOPLE SERVED t /EST. OF DAILY USAGE d0 al ❑ REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION M ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ®DUG []GRAVEL ®OTHER IS WELL SITE SUBJECT-TO FLOODING? YES ice' NO IF CELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. °— MATER WELL CONTRACTOR: Name IV. Address :,/_�;&!!0''� IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAHE OF PUBLIC WATER SUPPLY: "'' TOWN /VIL /CITY -"_'--_DISTANCE p `� °DISTANCE -10- :PROPEit^tY FROM NEAREST WATER MAIN : ; � ° � W -_� . • �- -- .. . . • . � - .... - .... , . ° . LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET (gate (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 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 oth •se contaminate surface or groundwater. Date of Issue: / 19�y Date of Expiration Vii) 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS RE IEW SHEET for CONSTRU N PERMIT NAME OF O R S STREET LOCATION BY f DATE Z_ TAX MAP, DOCUMENTS. Y. N­ PERMIT APPLICATION PC -1 WELLPERMTf; PWS LETTER. ® ENGINEERS AUTHORIZATION_ DESIGN DATA SHEET(DDS) -DEEP HOLE LOG CONSISTENT PERC RESULTS (3)_ PERC HOLE DEPTH CORPORATE RESOLUTION PLANS THREE SETS EHOUSE PLANS - TWO SETS VARIANCE REQUEST GENERAL LEGAL SUBDIVISION SUBDIVISION APPROVAL CHECRJD PERC RATE M FILL REQUIRED = CURTAIN DRAIN REQUIRED =]STANDPIPES M EX- APPROVAL SSDS ADJ. LOTS_ M WETLAND (TOWN/DEC PERMIT It & D) = DATA ON DDS PLANS & PERMIT SAME - ED PRE- 1969 - NEIGHBOR NOTIFIFICATION = LETTER BI/ZBA m 100 YR. FLOOD ELEVATION -- UIRED -DETAIT:S'flN °-Pi.AN -S SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE Q] GRAVITY FLOW D/ J BOX=] TRENCH/GALLEY I= P- PIT DETAILS ® SEPTIC TANK - SIZE, DETAIL WELL DETAIL, SERVICE LINE IF OVER CONSTRUCTION NOTES (GRINDER RATE) DESIGN DATA: PERC AND DEEP :RESULTS TWO -FOOT CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES CUT FOOTING /GUTTER/CURTAIN DIUJNS COMMENTS: =.DISCHARGE (OK) C�J PERC & DEEP HOLES LOCATED U, l REPRESENTATIVE OF PRIMARY AND EXPANSION Cl�] EXP. AREA, SHOWN; GRAVITY FLOW, SUFF.SIZE ®CIF PUMPED PIT & D BOX SHOWN & DETAILED = HOUSE - NO. OF BEDROOMS = WELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1 /4 "/FT. 4"0; TYPE PIPE NO BENDS; MAX. BENDS 45 W /CLEANOUT FILL SYSTEMS k / YBARRIER FT HORIZONTAL: SLOPE 3:1 TO GRADE LL SPECS EPTH GAUGES LL PROFILE & DIMENSIONS = VOLUME TRENCH �LF TRENCH PROVIDED 1�160 FT MAX PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN FIELDS EN'105 TO P.L., DRIVEWAY, LARGE TREES, TOP "OF FILL 201 TO FOUNDATION WALLS M/ 100 TO WELL, 200' IN D.L.O.D., 150' PITS 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATERLINE (PITS -20') P0' INTERMITTENT DRAINAGE COURSE 200 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS SEPTIC TANKS =10' FROM FOUNDATION; 50' TO WELL WELLS =15' WELL TO P.L._ YC: -1 ,1E'UVrM.& M COUNTY DE1PaA,1:1TMEWrr C:)V M1EALTH APPLICATION. FOR APPROVAL OF. PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant : 3 1154 �,710, T� a� -V'47 d�i4/�i ✓ /�J4' ' 2. Name of Project: J— �L2% l? V to 3. Location T /V /C: >' O�ll� �- Aer�o Cre' 4. Project Engineer. �1� t 5. Address: S License Number. Phone�6 6. Type gf Pro.iect: Y Private /Resi.dential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? A/v Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? .........A1G 9. Has DEIS been completed and found acceptable by Lead Agency? ....:.: . 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, or .other.officials,...ordinances? ..:.. ��. 12. If so, have plans been submitted to such authorities? .....�,/.�........ 13. Has preliminary approval been granted by such authorities? Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water round Waters 15. If .surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ..... ......................... a........... 17. Is project located near a public water supply system? ....... I........... Al a 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... Distance to sewage system W !0. Name of sewage system 1. Date observed: 23. Name of Health Inspector: !4. Project design flow.(gallons per day) ...... a.qg .......................... .25. Is State Pollutant Discharge Elimination System ( SPDES) Permit requi.r-ed ?..x,16 26. Has SPDES Application been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or.State wetland? .................................. ............................... 28. Wetland ID Number ................. :........ ............................... 29. Is Wetland Permit_.requ.ired? .................................................. Has application been made to Town or Local DEC Office? .................. 30. Does.project require a 'DEC Stream Disturbance Permit? %UG 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge. application or industrial activity? ........ YES or NO 32. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO a DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ........... 34. Are community water, sewer facilities planned to be developed within 15 years? ? 35. -Are any sewage disposal areas in excess..of 15 %, slope? �E 36. Tax Map ID Number. .................... ......................... 37. Approved'Plans are to be returned to: ................ Applicant Lf-longineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best: of my knowledge and belief. False statements made herein are punishable as: a Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. - SIGNATURES & OFFICIAL 'TITLES:, � MAILING ADDRESS: I/�����'r' /7rA �i /' /• PUTNAM COUNTY DEPARTMENT OF HEALTH ._ ...., _..._. _ _. _._ .. _. .. . . DIVISION OF ENVIRONMENTAL HEALTH SERVICES.- Date h� Re: Property of �r SZ -e_ Located ate- -`may �•�� , (TYr 1�)Ielol5®ction 71t 4 Block ,/ Lot Subdivision of Subdv.. Lot Filed Map 4 Date Pent 1 omen'.. This letter is to authorise �%�• �/ /� ��� 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 @11'necessary papers on my behalf in connection with this matter and to supervise the construction 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 , . Signe6�COi a a Owner of Property i. �1.- vvk 'A Address & i Town Telephone 4 • REGISTERED MAIL RETURN RECEIPT REQUESTED Building Inspector Date Re: Construction Permit for single family residence / Applicant 'z- Street e Torn - -__ -- TMO �_! W.— - - - -- Dear / 7 I"• �N/� /� - -- This Firm (1 ,am) submitting an application to construct a sewage disposal system serving a single family residence on the above captioned property, to the Putnam County Department of Health. In order to process this application the Health Department requires that the following information be obtained from your office: 1., Prior to your Issuance of a building permit A) Is Zoning Board approval. required for any variances? Yes-- - - - - -- No --- - - - - -- B) Is.any portion of the parcel located within a regulated wetland or its control area, and if so is a wetland permit required? Yea-- - - - - -- NO --- - - - - -- C) Is any other local permit or approval necessary? • _Yes- - --- -- No If the answer to any of the questions above is yes, please contact the Health Department in writing or by phone,.278 -6130 within 15 days of the date of this correspondence. If the answer is no, you need not respond to this correspondence. Name --------------- - -- Health Department Inspector JK /jp wetland bh Very truly yours, v Engineer, Architect, Owner Pumm •• jm . DEPARnma OF DIVISION OF •' •' ' E V L BEALTH SERvicEs DESIGN Lek- SHEET= SMSUFACE SEWAGE DISPOSAL SYSTFNi' F ice.._..._.__ Owner Address Located at (Street) ✓0r j.,k7 �i �� �° Sec. ;?J yBlock j Lot (indicate earest cross street) municipality '�� �� � t Watershed SOIL PMRMUTION TEST DATA RBWIR D TO BE SUBNII= WITH APPLICATIONS Date of Pre- Soaking - �' /-1 % Date of Percolation Test HOLE NUMBER CL CU 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 �7 l 4 ell 4 5 V 3 4 5 NOTES: 1. Tests to ba 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 measurements to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOUS Eb]COUN FRED IN TEST HOLES DEPTH ....:_..;HOLE NO.. G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' HOLE NO._ - r!/ w HOLE NO. 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �y,� // � 1� DATE: j DESIGN Soil Rate Used Min /1" Drops S.D. Usable Area Provided No. of Bedroans Septic Tank Capacity �G'CCJ gals. Absorption Area Provided By L.F. x 24" width trench i Other � f Nam �y�/ �� Signature Address S THIS SPACE FOR U,92 BY HEALTH DEPARTMENT ONLY: Soil Rate Approved . sq.ft /gal. Checked by Date A. ,.}`I �.. Y-, 'a y ,. - ..+�- r+•tia.^aw.,•'+++iw:."a. _ , i w.; or.-, a+. r'..:.`+w. r»^ r..... Kv*•- r+-••» ..er+z..;i- �:..�w..usa...L:�.•. IT ,, t 'N'" �..'+as ,�• r t f t r7 •c' it �`�ras*`� t ' ti I ` x��J r�r s i. � ' ' �,aawrl.+.= «e- rv- •i+.�..- `.�+r -erw,+ - _ - �� - �, f' � � - - + 1 t' V. WE 7777M L ,da t e k. t F �r � s r .° a., { _ .. ... -_ ,. .., _ ,x• «'>'Mi��t�;tdP +spe"�'smtw�ik�di��11�_ €'`'mif'a�a°"F.., �'� - . ..T.„�.�_; —�::v, ..J.s... -wawL '•dc fA71:ii0midlU'aAF3'V'@f3b9�P3k5 3 n w Putnam County Department of Health } "Division of Environmental Health Services h a 'Approved as noted for x _ .. conformance with r applicable: Rules. and F.egu a latons of. the kx _ Coun Hle341tthD�yeJpartment E r Signature :.8a Y Titl e ate 1