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HomeMy WebLinkAbout3764DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83. -1 -3 BOX 29 03764 16 r i jr y��� 03764 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES, Y CERTIFICATE OF CONSTRUCTION COMPLIANC TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # l Y- Z 3 l� / Located at ��Y'c e-10 f r- Town or Village Ile- If Owner /Applicant Name IlaAIJ crv'-V C.�e i dr u Tax Map 93 •0 Block i Lot � Formerly '—' Subdivision Name �_ .5 el- Mailing Address Subd. Lot # �- Zip /cis /-0 Date Construction Permit Issued by PCHD /H'3 Separate Sewerage System built by �rc� �%� %�ie f Address %' ® �X `��y Consisting of % 7— _S'Cl Gallon Septic Tank and '1 X7-0 'r 7" '-'7 W C A- Other Requirements: Water Supply: Public Supply From. Address or: Private Supply Drilled by C,^r N 9goa % Addresses j C� � �i - - . Building Type- - 94--$ / V' Yr-? Has erosion control been com et ?. Number of Bedrooms 4— Has garbage grinder been installed? )V V I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. . Date: Z�' � Certified by P.E. �°" R.A. v ofess►6 Address License # ` 07 9 An e n occupying remises served b the s sterri(s))s promptly take such action as may be necessary YP PY gP Y p to secure the correction of any unsanitary coneC"i" aresulting from such usage. Approval of the separate sewage treatment system shall become null and void as s afs'a public sanitary sewer becomes available and the approval of the private water supply shall become null and void` hen a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, m dific 'on or ch a is necessary. By: Title: H-1- Date: 2'8 0 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY (DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMIPLETION REPORT �-- �- +:,�E'cP% ":�!c!C3'.`�'s9:z .._- .. .. Angela Drive • ©WrtlVilfage� Putnam Valley Tax- Grtai#�" Map Block Lot(s) Well Owner: Name: Address: Marion Conwa , 10 Westerly Lane So., Thornwood, NY 10594 Use of Well: 1- primary 2- secondary _x Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length eft. Length below grade 52 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel Plastic Other Joints: _ Welded X Threaded _ Other Seal: __X., Cement grout _ Bentonite Other Drive shoe: X Yes No _ Liner Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 6 gpm Depth Data Measure from land surface- static (specify ft) 30' During yield test(ft) 200' Depth of completed well in feet 265' Well Log If more detailed information descriptions or sieve analyses _ aze available; '_ please attach. ..Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 2 D 26 Hit rocc at 26' _.•..26 ;.,. _ :._ . _ ._" 53. -: '. -:; Drlli 53 F 265 Drillij2jj in rock granite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5=m Depth 220' Model 5GS05412 Voltage 230 HP — 1;5 Tank Type olume Date W if Comp ete 8/25/98 Putnam County Certification No. 002 Date of Report 8/20/99 Z D 1 Nu rh: txact tocatton of well wttn atstances to at Well Driller's Name P. ,fir. Signature: permanent tanamarKs to oe provt a on a separate sneevptan. Putnam Avenue Address: 'Rt w� •,c,,,f cr, rry 30509 Date: 8/20/99 White copy: HD FilWYellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 YML ENVIRONMENTAL SERVICES . 321 Kear Street Yorktown Heights, N.Y. 10598 .Ivy/ (9k4l` 2450800 Albert H. Padovani, Director LAB #: 32.?05159 CLIENT #: 10994 NON STAT PROC PAGE 1 FLORIO, MATT DATE/TIME TAKEN: 08/19/99 07:00P 189 TANGLEWYLDE RD. DATE/TIME REC'D: 08/20/99 03:50P LAKE PEEKSKILL, NY 10537 REPORT DATE: 08/27/99 PHONE: (914)-528-7275 SAMPLING SITE: 23 ANGELA DR. : PUTNAM VALLEY, COL'D BY: MATT FLORIO NOTES...: LAUNDRY ROOM SINK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD ^ PUTNAM CNTY PROFILE 08/E0/99 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 08/20/99 LEAD (IMS) 1.2 ppb 0-15 ppb 9101 ' 08/20/99 NITRATE NITROG 0.80 MG/L 0 - 10 9139 08/20/99 NITRITE NITROG <0.01 MG/L N/A 9146 08/20/99 IRON (Fe) 0.203 MG/L 0-0.3 mg/1 2087 08/20/99 MANGANESE (Mn) 0.20 MG/L 0-0.3 mg/1 2037 08/2009 SODIUM (Na) 8.91 MG/L N/A 08/20/99 pH 6.2 UNITS 6.5-8.5 9043 08/20/99 HARDNESS,TOTAL 80.0 MG/L N/A 08/20/99 ALKALINITY (AS 40.0 MG/L N/A 08/20/99 TURBIDITY (TUR 1.5 NTU 0-5 NTU BACT THESE RESULTS INDICATE THAT THE WATE QCOMMENTS: S NOT) OF A SATISFACTORY SAN%TARY QUALITY ACCORDIHE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ublic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet°the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. YML ENVIRONMENTAL SERVICES . 321 Kear Street ___�=Yorktgwn Hei ht N.V. 1{)596_ All Albert H. Padovani, Director LAB #: 32.905159 CLIENT #: 10994 NON STAT PROC PAGE 2 FLORIQ, MATT DATE/TIME TAKEN: 08/19/99 07:00P 189 TANGLEWYLDE RD. DATE/TIME REC'D: 08/20/99 03:50P LAKE PEEKSKILL, NY 10537 REPORT DATE: 08/27/99 PHONE: (914)-528-7275 SAMPLING SITE: 23 ANGELA DR. : PUTNAM VALLEY COL'D BY: MATT FLORIO NOTES...: LAUNDRY ROOM SINK ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ . SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERA . E..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~"~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY" WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT'TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L -- ` M�OA�D�ED�RW6YT�E�LEYYt�.H~-A�R�D 0 �3WA00TE Rt 70 ,f 40 MG /L - . �� IBRA ER- MBV- --1-C--491 6, �iioiT - -~' ^ - ''----- -- SUBMITTED BY: �_____ Albert H. Pjmovani, M.T.(ASCP) Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION_ _..��.; ,i Date:_ Irf ected by Street -Loci 1 C -- . �2�� F Owner � &4' Town TM 4,' , —1 -3 1. Sewage System Area . a. STS area located as per approved plans .....................:..... b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course/ wetlands ...... ............................... II. Sewage System a. Septic tank size - 1,000 ......... 1, 250 ......... other ................ b. Septic tank installed level ............... ...............:..............I c. 10' minimum from foundation .......... ............................... d. istribtuion Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches Junction Box - properly set ................. ............................... Length required !Length installed'' 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ................... :.................... 4. Slope of trench acceptable 1/16 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 1 %2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... - ..._ ..1.1J._: ipe e.�a, vupptu ......................... ..-............................ g. Pump or Dosed Systems Size ot pump chamber ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildin a. House located per approved plans ... ............................... b. Number of bedrooms ....................... ............................... IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall tiVorkmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ...................:........... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. n---. Erosion control provided ................. ............................... IM" Permit # i 3 Subdivision Lot # � DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM a Goy r�ri r! j' cr !7-3 ! 3 Owner or Purchaser of Building Tax Map Block Lot ,/ Building Constructed by L co it onrStreet Building Type _e_- � �� 6 t V2 f - V Town/Village Subdivision Name 2, Subdivision Lot # I represent that J am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is 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 treatment system, 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 determination of the Public Health Director 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: Month 3— Day a Year 9 Signature: Title: ` —6- vv� � a w V-k G"� C_ . V (Owner) - Signature L4. A C ration Name (if corporation) Zd7roe ra/16A< ss: State Zip ��� O-A 3A- Corporation Name (if corporation) Address: State Zip Form GS -97 4 r 4• r rz - 1�Jar� ✓�� ''� �jR � �'. r+��. � �� � . • � � `ate _ �.._�;rP � ' yW Fi+' I f i� •. X f y • y`'„y ty- k �3,y(�y{. ;g, < }VX ® ^. 1 k f N �4 1J 1 y� 9 r r y- tx: 3 c xr fit, KIWI, Or, how I /,a:� I Z�v�yB =f, t j T. WOW man oil as �` Y a aA P 2 'x f 6 PQTNAM 00UNrY DEPARTFAM OF HEALTH Dividm d Bawb o onow HeaNA SWVI & CaeeteL N.Y. 10512 Ids Persil a• CERTIFICATE O CO PZMr FOR SEWAGE DEPOSAL SYSTEM Peace 0 4 e.11 0 1 ' Iocled d � of • R l ' �tiY °17�i i"/�''ebd" lot i Tau Mop' Renewal OweedAppY.t e. M. r�`v r� (.cJ p✓pi RHO° ❑ Date d Previous Approval � Aarse �r a y C EJ /'! / U d Town' ui`✓ `�'3 iv ZIP An 7l d . Date Subdivision ARRroved Fee Enclosed 1:1 Amnnnt- Type Lot Area 'L $ 7,9 �c FW Sedloo o4 LJ Depth vdame N= b. d Hmha M Design Flow G P D PCHD NotiBcatlon In Required When Fm Is completed Sepeeats Sewerage Syagem m ooao(at d Godoo Septic Tank .rya 412 L To be of a skeoted by Adtr exx Water Sap*- P* Sm* Fitota Address on /' wa.,.f. Sap* DAW by sd&m other Re"kemeata 2-' 1 represent that 1 am wholly and completely responsible for the design and location of the pr qm(s); 1) that the separate sewage disposal system above described will be constructed as mown on the approved amendment there to and to a pc9J . anderds. rules a regu ns 01 • Flulmarn County Department of Heaith, and that on completion thereof a "Certificate of Co tisfactory to the Commialoner of Health will be submitted to the Department, and a written guarantee will be furnished the ow assigns by the builder, that raid builder will piece in good operating condition any part of said sewage disposal system duri f immediately following thedat• of the issue once of the approval of the Certificate of Construction Compliance of the origi a t o; 2) that the drilled well descrHl•0 above wHl be located as shown on the approved plan and that said well will be installed in a st rules and requ glons of the Putnam County Department of Health. Date j74/1 c� Signed P.E. � RA. — r Address 7- 7 %� A9r1i G r�°> /IY icense No �J 9-9s— APPROVED FOR CONSTRUCTION: This approval expires t1/, rs from the dat i ad on of the Adding .has been undertaken and is revocable for pus or may be amended or modified when co or n essary by Commi 1 Health. Any change or. alteration of construction �v. /equir� eve rmit. Approved for disposal of domestic a sewage, a ivate water supply only. 1.088 Da' Title '� (/f7 BY Title ,:,... -.+ r ,r;,.: -; ...:�.. ..,,�.;•- .."_? '.::r - a'�-rf "'m�,n•'.ro'm++^*;v""z�.c t. {:. "...rR`tmas sr,?+."t*.'�'r,'?^',' �' �Y"""i"�r -+ ° r� — - �..;�g �, � ?. 3S `�J '' _ ': - sue. . �.i i��i :~ •.�0�°",t0 ��lalaww +aN ,POD sBWA� tl/ SYSI�i /- �a i ol`f Lsedat s� en Ov�adA�Yest Nor � � ' Dllt® of Pwvbis A1pp.m ret Date Subdivision A6Rkgved Fee .Enclosed s / �� Gi (iJ>�!G Got Ahem •2 ��f. F®:Sectlota 0.* .• µdal>tme Elvbdtr d Bostaa �' Deatgtr D Flow P1ffi b sam em oaeelet sd > , � Gam Ta®k` r® �e oeWd.ded 69 Addrm WOW S�pb: /P�ls Sappb Fns 1'reprgMt that 1 am vubolly aMeompWtaly rospon i0ls for h� design and bcation of tM propoied tYst ®m(s) 1} t�ah tB ate. shwa i'dis ofil s stem . above deferi0id will a constructed as shown on the approvo0 amendn}ont tha►e`to an11 in aeeorda�ce witmhe Stan" �u( a ons o • -e ham Count Oepirthux+t' of tMelth;' and tMt on conipNtbn tn�reof a Certificate. -of Construction Compliance' y� fie issbe»i, Meatthwill 'tie w_bnHttet7): -to, tM't>•pa�tinent and: i, w�ltten ,gwrante�,.will_M>tumisMdaM, own► his;sucospas, Mkt tthat Paid bYilder wlll Opcn b pd0 opwatinp sonditbn any. part of_ p{d t:e►aba disposal systm durirq.`tAO psrb6:'of two;(2)' tMdato OfaM istu anoa 'of the _ ppoval of tM {NtNieate . of Construdkfn Gompliancq o1 tho original sYStMhor any rogMs : 2 t e I :d:aeaew above WIN Oe bested as d"W" on the,gpproved Plan and that Ykl wall will be- installed 'In acoor0a w tM ,>Q ru s of the ' putMm Ceisnty DaOYftnNht of /featth' Dab � •. n Address .✓ i` tt5l�gf''y.�!T� APPROVED FOR- CONSTRUCTIOH T, s approval.expMili two years ,Prom he, daU issued lets construction of`'' 6v ' i 1,,;/s been undertaken and is _. g9.a�!e_r, revOCabkt for:uuse•or may be" a- or modified when -eon eeesYry'by the ommissioner of 'Mw1th. Any or attsiatbn of corutruetbn requNes L'new eFmit. Q/►ppiowed for disposal o4 domestic a and/ A,atte`wata supp�% o�,ly/J- Mv.' Date G . ®y !'v ~ Title m DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 ..• ..- mn N••. ::>... .� .4.. :.:� r APP'LICATIO1VwT0� CONSTRUCT A WATER WELL PCHD PERMIT # I WELL LOCATION Street . Address YJ e d Town /Village Cit Tax Grid Number r , !, te. ✓/771 � ; -_3 WELL OWNER NaAe /%�"'iv'� Mailing Address z / 3 G rivate O Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL BUSINESS 0 INDUSTRIAL PUBLIC S1 LY O AIR/ CO /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT Sv gpm /# PEOPLE SERVED _- /EST. OF DAILY USAGE X&"d gal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY O TEST /OBSERVATION CIADDITIONAL SUPPLY Allad SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN DDUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES --' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. L WATER WELL CONTRACTOR: Name Address:�a/y��'� !� IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _,4,,_NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY __DT�S I!IGiF .lSy :.P1�OPf?FTY .k:RnM . NEAREST_ TrI sTER_M_ T_AT.:___✓'ilr�� LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED /J / ON SEPARATE SHEET (ddte) (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 drilli operations be contained on this property and in such a manner as not to degrade or otherwi cont ate surface or groundwater. Date of Issue: A 1 19 Q I JA _ AA-_ Date of Expiration 19 Permit Issuing Official It Permit is Non - Transferrable White copy: HD File Pink copy: Owner \3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New-York 10509 (914) 278 -6130 APPLICATION ; -TO '. CONSTRd& A WAPER- WM; r. PCHD PERMIT WELL LOCATION Street Addre s Town Villag City Tax Grid Number WELL OWNER N e /°%rr�b�iJh Mailing Address 3 7 atv� Private W 5 A4V Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL 9BUSINESS 0 INDUSTRIAL ❑PUBLIC SUPPLY QAIR COND /HEAT PUMP 13ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT S gpm /#. PEOPLE SERVED 4 /EST. OF DAILY USAGE gal gal REASON FOR DRILLING E3 REPLACE EXISTING SUPPLY O TEST /OBSERVATION 13 ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED ®DRIVEN ®DUG OGRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES l/' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ;J +�✓ ' A' Lot No. WATER WELL CONTRACTOR: Name jVAV rrfUrl Address:../?�l��f% IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES j✓' NO NAME OF PUBLIC WATER SUPPLY: -` TOWN /VIL /CITY _DISTANCE TO PROPERTY. ,FROM .NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON SEPARATE SHEET � 9,/ (date) CJ (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 thirt -y (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 other w a conta 'pate surface or groundwater. Date of Issue: �� ' 19 /L�4" Date of Expiration Jl 19 G1)� 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 INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL REVIEW:_ SHEET for CONSTRUCTION -PERMIT NAME OF R STREET LOC TION BY DATE l TAX MAP# ll_CUMENTS. v Y f.-DISCHARGE (OK) ERMIT APPLICATION r PERC & DEEP HOLES LOCATED P REPRESENTATIVE OF PRIMARY AND EXPANSION LL PERMIT; CD PWS LETTER JEXP, AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE G EERS AUTHORIZATION F PUMPED PIT & D BOX SHOWN & DETAILED lJU DESIGN ESI= DATA SHEET(DDS) OUSE - NO. OF BEDROOMS 'EEP HOLE WELLS & SSDS'S WAN 200 Fr. OF PROPOSED SYSTEM I PC,ONSISTENT PERC RESULTS (3) P PROPERTY METES & BOUNDS NERC HOLE DEPTH— HOUSE SETBACK NECESSARY (TIGHT LOT)— ED ORPORATE RESOLUTION HOUSE SEWER - 1/475T. 4-0; TYPE PIPE PLANS THREE SETS NO BENDS; MAX. BENDS 45 w/cLEANour HOUSE PLANS - TWO SETS FILL SYSTEMS VARIANCE REQUEST MCLAYBARRIEER F9GENERAL 10 Fr HORIZONTAL: SLOPE 3:1 TO GRADE GAL SUBDIVISION FILL SPECS SUBDIVISION APPROVAL CHECKED DEPTH GAUGES PERC RATE FILL PROFILE & DIMENSIONS M ILL REQUIRED IVOLUME CURTAIN DRAIN REQUIRED MSTANDPIPES TRENCH 0cX-AP SSDS ADJ. LOTS BIJLF TRENCH PROVIDED L E =LAND (TOWN/DEC PERMIT R & D) EI,-kO, FI` MAX ATA ON DDS PLANS & PERMIT SAME [AfrPARALLEL TO CONTOURS rvi PRE- 1969 - NEIGHBOR NOTIFMCATION E;]"ON. EXPANSION PROVIDED ,U=R BI/ZBA SEPARATION DISTANCES SPECIFIED ON PLAN .0ff 100YR.TLOOD ELEVATION— FIE TA 'GN fflo REQUIRED-Dr- Its N-PLANS—­ l-,'D']RW DRIVEWAY, SEWAGE SYSTEM PLAN - (NORTH ARROW) 20' TO FOUNDATION WALLS �4 r 106 TO WELL, 200' IN D.L.O.D., 150' PITS SSDS HYDRAULIC PROFILE III GRAVITY FLOW D/ J BOX ED TRENCH/GALLEY ED P- PIT DETAILS 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN) SEPTIC TANK - SIZE, DETAIL TO CATCH BASIN, 35'.STORMDRAIN, PIPED WATER vis. LL DETAIL, SERVICE LINE IF OVER El I 'TO WATER LINE (PITS-20') LD L ONSTRUCTION NOTES (GRINDER RATE) EE 50' INTERMITTENT DRAINAGE COURSE DESIGN DATA: PERC AND DEEP RESULTS 1-11--wo Fr. RESERVOIR, ETCJ= 150 FF. GALLEY SYSTEMS 0 -FOOT CONTOURS EXISTING & PROPOSED SEPTIC TANKS fDRRIVEWAY & SLOPES CUT I O'FROM FOUNDATION; 50' TO WELL FOOTING/GUTTER/CURTAIN DRAINS WELLS Z1,'5' WELL TOP.L. HEALTH SERVICES SYSTEMS :OMMENTS: PC -1 APPLICATION FOR APPROVAL 1 Name and Address of Applicant: 7 i�,O--1 y.✓a �T .� l✓' C�a y �� G�4�- 2. Name of Project: 3. Location T /V /C: �}`.r1C,�' d✓tif/ 4. Project Engineer: �C/ P 5. Address: 164zeVA'//4'&- License Number:_ 9s Phone:/V2- 6. Tvoe of Project: i Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEAR)? /j/G Tvoe Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft.Env.ironmental Impact Statement (DEIS) required? ............. _ 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 10. Name of Lead Agency �G 11 : is t'i °iis-pruject i n 1re�- �n r-.thd_.cn- Antr- 1-- of- .lacai _planpirg, .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 lV Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? .................. Ale 18. If yes, name of water supply Distance to water supply H mss i9. Is project site near a public sewage collection or disposal system ?..... Ala j '0. Name of sewage system Distance to sewage system '1. Date observed: 23. Name of Health Inspector: 14. Project design flow (gallons per day) ...... ............................... 4-1 �,.-:::2.5: - I-s.State Pollutant Discharge- El -i.mi. nation.. System - -, ( SPDES). Permit required ?.._____�p 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 ........................ ............................... —P, 29. Is Wetland Permit required? ............... ............................... Aid Has application been made to Town or Local DEC Office? .................. '> 30. Does project require a DEC Stream Disturbance Permit? ................... A4G 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 DESCRIBE: All! 2. 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? 3 -5: A-re—any.-se aqe -. dispes 1- 5_reas.Jn.:e.xcPss —cf.f 159:.s:1- 0 pe�:,•: 36. Tax Map ID Number .......................................................... -3 37. Approved Plans are to be returned to: ....:........... Applicant _� Engineer 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: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .........: ,.r�, 4t :' Y. k...:. .... .;•a. n._ .. _. . -.:.z �•o� -s i�.,:!�a ..- ;.. xa -: ...._ .. -.i -w. v:;. ..:�.� -k -. .'. w^.�Fw:¢:v >. W- Y.. :. F ,' .er -. e- +� v .. ...a ._ v .a�... .._ .c' a �. Date Re: Property of Located at 4-11'a Section �f�'. / Block Lot Subdivision of -fae '% Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize�`%�✓/ 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 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. r Countersigned: P.E. /I'. A. 7 � Address Telephone Very truly yours, Signed O�hier of Property Address Town Telephone PUTNAM COUNTY'DEPARTMENT OF HEALTH DIVISION OF ZNVIRO-NMENTAL HEALTH SERVICES Date ✓�/ '19 / Y Re: Property of Located at ,� ---7- " (T)/�c' . Subdivision of Section / Block Lot 3 Subdv. Lot Filed Map Date Q�ntl�mu� _ : • This' letter is to authorise a duly licensed professional.enSineer'• or.regiattred 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 or Health, and to sign all 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 �' Y 147, Education Laws the Public Health Law, and the Putnam County Sani- ",ry Code. Very truly youras Signed Countersign$ ', of ''''rje AAA eas _ f �1'elephone �~ fth�er of Properrty Addres , 'A C2��v Toft n OV5 5 Telephone DESIGN DATA SHE ET- SUBSUFACE SELVAGE DISPOSAL SYSTEM _ _ _ _ _ . ./FILE. N0. d�`r %� .✓.'yJ G�/�° _ r Address Located at (Street) 14�14�1 -1 ���J•� Sec.-:,- / Block Lot -a r� Undi to nearest cross street) Municipality /ill Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMIT= WITH APPLICATIONS Date of Pre- Soaking 11 l 4� Date of Percolation Test / �6 HOLE NUCER CLOCK TIME PERCOLATION PERCOLATION 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 2,),j7 3 33�L�s 2-7 4 5 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 suhaitted for review. 2. Depth measurements to be made from top of hole. rev. 9/85 TEST PIT DATA RBQUMM TO'BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES kd; N0. -HOIS NO. HOLE Wi. G. L. 21 31 41 51 61 71, if C1-1 131 INDICATE IZVM AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE I&VM TO WHICH WATER LEVEL RISES AFTER BEING. ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: 21�3 0 � DATE: DESIGN Soil Rate Used 7—)& Min/1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity _gals. TypeA/d--5- Absorption Area Provided By #-4V L.F. x 24" width trench Other 15, OF Name tore Address THIS SPACE FOR USE BY HEALTH DEPARTMENT Soil Rate Approved sq-ft/gal. Checked by Date