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HomeMy WebLinkAbout3766DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83. -1 -5 BOX 29 VQ Lm III L �Ti {ri' EI 1 03766 y Put"M COUNTY DNFAR'MNT OF HEALTH /f �P7% Dleliw it Bnii<eae�W'BedMA Senloea. Csarsd. N.Y.1�61? ` -ME ,absi r b Foi" Ffamb M a ATE OF COMhUNCE 3 a FED lift Sff iYr►6E•DWOM SYS!ffi1l / Fefolt M Py �r ' �7 H�i1 f7lGi Q, �°� / • J �V: _ff _� _.a' . . : :-. r =,r �. .•r ` :, _ a- te_ ► N�lr y 6 ,�e, c //ih� d /�y" d t7/!� /� Dafae ait Frevtooa . -A.p. pfovd Ressewid-0 tTlnt-o fr idd Tdwa � zip' nhdiv icinn ❑ Annrnved Fee F.nrinGed ❑ A,,,,,.:,.t 1 rwasent::that 1 am wholly, and eoanpleWy resoonfibr for the :design and location of the proposed systom(s); 1p that the separate saw • tlifpO'a' s stem above desarised will be constructed as shown Oat the approved amendment there to and in accordance with the standards, rules an reyu tong e na County department Of Hmlth and that on completkin thereof a "C4kifieste of Construction Compliance" satisfactory to the Commiss+onw.of HeaNhwill be submitted to the department. ind :1. written quaiantee will be furnished the owner, his W ' sa01; .hews or asigns by the builder. that fa builder will /bce N petl .00eratkq eondMwn` any psi►t _ of _sold sewage disposal system during the 2) ywf Immediately following tladate of the h»u- ance of the approval of the Certificate of Construction Compliance of the original t or �v tiwreto; 2) that the drilled well despibed above WIN be tO AW as shown on the approved pian.anal that saki well will bs,installad in a rules and reg�Of the Putnam County Depaftnaen of Health „�. Date] SiitMtl f% APPROVED FOR.CONSTRUCTIONc This approval expires two y. rs romthe t u str of the buildity seas bean undertaken and is IMOCepki far caVf er maY W amended or motlified when aonsi M YIy bY. t Any Change 01 altwatiOn_ O} constfuCtbn '"uhes a new rmit. ApOrovetl for disposal OP dOmastk n aye, a nty. Rev. 2- Z_ r 10/88 We— BY f Title ,o,.,.,�.,m•*m�^.:.r. -.. ,..�,o- -.,+- :r^-.,:,�w- +«r's ^^*'ra„t �H. j >a.,::, ra - ,.�.,nr^ ,,...- c L OO�FSP�'DSPA�' . of SaevOoae: O� HEALTO Cmsl®el. !I •Y Esil4l8 Peeeilt �+, ma C8 TB18 p��� . i Pee""" it � COIf51l�iCliO "M UWAq; DMPOiAL SYSl�1[ t4omw at T. ltd x • r d_ $bootie(_ ❑ Bevlaiaa -p Omw/Affffiew d fbm � Deft of 1taWM mg.Adiwa .. .`�� / .:.. .. To=.-. Date Subdivision A'npriived _ Fee Enclosed emn;;rit. above al county e. 'sam ptsee ;in ana.'of Date APPROVEO FOR CON MrYcabta for'caliie Or 1 reeutres INw permit; Ith V. S ipnoA i►aaro� n A/ Rev. 2 3r'3 10/8.8 oae. er te'rot Constiuctio� Compliantr satisfactory to,tM CommisfWner of MNKhwill ,. tho owner, his wccessois, s by tho builOsr tMt tN0 builds► 'will m AurinO tho period o4 t ) biy followirN tMdate Of °tM inu- ie,oriainal st em O► any i t ll drilled well Oefpilm atrore "in aeeordanp with+ 1tWp:' nYulai Oni of 'tbe' Putnam R.A. re `.date i uniess co nb her W" undik k" and is y,aby the Co ml signer oVy,. y or alteration Ofconstruction ® Tor pr t0 wbter supRl�.apA1l, s. �' Title IS WELL SITE SUBJECT TO FLOODING? YES A-' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name /� �/,� ��'� Address:. Ar�"'r//'y IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 10' NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ..DISTANCE T0._ PROPERTY- :- FROM.. NEAREST. -WATER . MAIN.:. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ❑ON SEPARATE SHEET (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 Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health 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 of wise contaminate surface or groundwater. Date of Issue: 3 3 19 Date of Expiration r "16— 19 Permit Issuing Official I' 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 SHEET for CONSTRUCT ON PE IT _ - - ---._ _ �:, � _.. _.. NAME O OWNER G. Oi .F. s STREET LOCATION ' lllifi - T BY DATE TAX MAP # 4+ 4-s- DOCU TS. YN APPLICATION R"I C -1 ___JELL PERMIT; PWS LETTER [[tt�� GINEERS AUTHORIZATION ESIGN DATA SHEET(DDS) EEP HOLE LOG ONSISTENT PERC RESULTS (3) PERC HOLE DEPTH ORPORATE RESOLUTION S THREE SETS HOUSE PLANS - TWO SETS M VARIANCE REQUEST GENERAL �L SUBDIVISION )IVISION APPROVAL CHECKED ;RATE REQUIRED CAIN DRAIN REQUIRED MSTANDPIPES_ r PPROVAL SSDS ADJ. LOTS LAND (TOWN/DEC PERMIT R & D) A ON DDS PLANS & PERMIT SAME 1969 - NEIGHBOR NO, I�IFICATION ER BI/ZBR. FL7OCO . ELEVATION Syr •••.•: �cEyi'iJ1RI;DDE 1!i'Y�J- V1VT..P LA1-i 0 ..•.••• • .•- ..- , M SEWAGE SYSTEM PLAN - (NORTH ARROW) M SSDS HYDRAULIC PROFILE m GRAVITY FLOW M D/ J BOX m TRENCH/GALLEY m P- PTT DETAILS M SEPTIC TANK - SIZE, DETAIL M WELL DETAIL, SERVICE LINE IF OVER M CONSTRUCTION NOTES (GRINDER RATE) M DESIGN DATA: PERC AND DEEP RESULTS — M TWO -FOOT CONTOURS EXISTING & PROPOSED M DRIVEWAY & SLOPES CUT M FOOTING /GUTTER/CURTAIN DRAINS COMMENTS • M DISCHARGE (OK) m PERC & DEEP HOLES LOCATED m REPRESENTATIVE OF PRIMARY AND EXPANSION m EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE m IF PUMPED PIT & D BOX SHOWN & DETAILED CD HOUSE - NO. OF BEDROOMS m WELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM m PROPERTY METES & BOUNDS CL] HOUSE SETBACK NECESSARY (TIGHT LOT) m HOUSE SEWER - 1 /4 "/FT. 4"0; TYPE PIPE m NO BENDS; MAX. BENDS 45 W /CLEANOUT FILL SYSTEMS LAYBARRIER HORIZONTAL: SLOPE 3:1 TO GRADE ILL SPECS GAUGES LL PROFILE & DIMENSIONS VOLUME TRENCH =LF TRENCH PROVIDED =60 FT MAX m PARALLEL TO CONTOURS m 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN FIELDS W, TO P.L., DRIVEWAY , LARGE TRELS, TOP OF FILL m 20' TO FOUNDATION WALLS m 100 TO WELL, 200' IN D.L.O.D., 150' PITS m 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN) m 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER m 10' TO WATER LINE (PITS -201 m 50' INTERMITTENT DRAINAGE COURSE m 200 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS SEPTIC TANKS 10' FROM FOUNDATION; 50' TO WELL WELLS C1� 15' WELL TO P.L. ref, 0 A) - _.,,., .. _ .::D� =G�7 :�';� LN.�T•°.��r:w'v�Yt:E=•�• 'IiIS'-r' �i�I; SYu�''.� r i .:.::. �_ ,.. �,IT,� Lv�Y:..:... _... ......: , ... -- ,- .... Owner ja %'y1 Address , wAe,-W ✓ %lel Located at ( Street) 19P 4e.,1,o r % rC Sec. ;• Block Lot (in to nearest cross street) municipality ;:t�' ��. Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMr= WITH APPLICATIONS Date of Pre - Soaking �� /� ��' Date of Percolation Test�� HOLE NUi M CLOCK 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 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 submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 r, TEST PIT DATA RBQUIRED TO BE SUBMITTED - TH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED" IN. TEST',-HOLES IJ HOLE T�10 :� �i3OLE N0. - 1' 2' 3' 4' 5' 6' 7' 8' 90 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNMATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided No. of Bedrooms ,_3 Septic Tank Capacity /PaG' gals, Type o �-J. Vq��° Absorption Area Provided By L.F. x 24" width trench / other Name . ° �1� �-�'/ �i �4� Signature Address Z'%% P' rliCr* �-t° SEALS 1LL117 &AC-A-AX-Ij USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sgeft /gal< Checked by Date DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner Address :• • -. _ ti's `'. 1� .ar.. M /��/ dfl L/ J 'r �i . Located at (street). ,<s /� ,�i-i `"� Sec. 9z3.) Block Lot JS (in to nearest cross street) Municipality itq /`770/0? /� �'�` Watershed.. SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking — Date of Percolation Test/ e --j-, HOLE KESER C= TIME PERCOLATION PERCOLATION Run No. Start -Stop Elapse Tine Min. Depth to Water Fran Ground Surface Start Stop Water Level In Inches Drop In Soil Rate Min/In Drop Inches Inches Inches 2335- 31 /(C� 4 61 0 3 3 y 37 y 2-2- 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 subai.tte3 for review. 2. Depth measurements to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED i, e- s INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED e DEEP HOLE OBSERVATIONS MADE BY: rT ��'� /�/ DATE: �d DESIGN ,off© � Soil Rate Used � Min /1" Drop: S.D. Usable Area Provided � No. of Bedrooms _3 Septic Tank Capacity % 0062 gals. Type 046-11% Absorption Area Provided By 34"0 L.F. x 24" width trench Other Name Address 7 Z )!°-2 C THIS SPACE FOR USE BY HEALTH ^w y Signature SEAL 1411�a- Soil Rate Approved sq.ft /gal. Checked by Date DESCRIPTION OF SO'[ns EN(XXD WM IN TEST HOLES .... - ..1•\TLVTI�7 ..J I.0PY. .TwdC • r 6 'HOLE;. �Oi U�Ar G.L. d / 1° .21 � ezo 3' 4' 5' 6' 7' 8' 9' 10' 11° 12' 13' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED i, e- s INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED e DEEP HOLE OBSERVATIONS MADE BY: rT ��'� /�/ DATE: �d DESIGN ,off© � Soil Rate Used � Min /1" Drop: S.D. Usable Area Provided � No. of Bedrooms _3 Septic Tank Capacity % 0062 gals. Type 046-11% Absorption Area Provided By 34"0 L.F. x 24" width trench Other Name Address 7 Z )!°-2 C THIS SPACE FOR USE BY HEALTH ^w y Signature SEAL 1411�a- Soil Rate Approved sq.ft /gal. Checked by Date 0 PUTNAN COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONNENTAL HEALTH SERVICES _. Date Re: Property Located a (T) Subdivision of tion Block Lot SubdV. -Lot ]Filed Map * Date Geatleaeut This letter is to author x a duly licensed professional engines. '• or• regisLred 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 promulagsted 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 coafor ity. rith -'the- provisions-'6f Artic3e �t5 or -__ 147, Education Law, the Public Health Law, and the Putnam County Sani- - wry Code. r Countersigned: Pose, Rj A -9. one Very truly yours. c Signed Owner of Property— - Addr s Ae Town Tole-phone Rev. - 3/86' F' ,y rt,.. u^ PUTHIAAY COUNTYbDEPARTAi[ENT OF HEALTH Division of EnvleonmentalHealth Services, Carmel, N.Y. 10512 Engineer Mu Provide — P.C.H.D. Permit N -- — a7 Tax Map �.` Block _Lot: Subdivision Nam e/° /,xe Sabdv. Lot # Date Permit IssuedGiv'��. Separate Sewerage System built by do) W 1;% 1i % Address Consisting of Gallon Septic Tank and Water Supply: Public Supply From Address or: Atf*' Private Supply Drilled by V1 e- a Address 0gV`1 � Building Type ;,� f - 1,2eHas Erosion Control Been Completed? Number of Bedrooms � oarbage Grinder Been Installed? j Other Requirements 7' l I certify that the system(s) as listed serving the above premises were constructed essentM plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulat in aed an, and the permit issued by the Putnam County.D partment Of Healt Date �- Certified by P.E. R.A. Address . Lluanse, No�� Any person occupying premises served by the above system(s) shall promptly take such actio b. he uro tho correction of any unsanitary conditions resulting from such usage. Approval of the separate satyr system Shall boco 6 as 0 publ(: sanitary sawor becomes available and the approval of the private water supply shall become II n void when ub i omen availablo. such apprbvals are subject to mo ificat n or change when, in the judgment of the o over o4 H such Iflcation or chango Is n ►y. k Date "� ° By Title l UC_20 . AA1.RT1T TmTALT nr.+nnnm .0 WPaLL 1rV11r LP�11Viv �r.r VAt DEPARTMENT OF HEALTH- Division Of Environmental Health Services PUTNAM COUNTY Office Use Only WELL LOCATION STREET AOORESS. wN /vll 1 I Y TAX GRID NUMBER: le-a ( z Z^ a Ile 44 /41 WELL OWNER NA ADDRESS: S to ()4e i� l Vc ��p PUBLICS USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR /COND. /HEAT PUMP ❑ ABAN ED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING W SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 3 b v ft. STATIC WATER LEVEL a ° ft. DATE MEASURED I°Z ��� DRILLING EQUIPMENT ®- ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED 0-0—PEN END CASING. ❑ OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH ft. MATERIALS: 0-&T-EEL O PLASTIC ❑ OTHER CASING DETAILS LENGTH.BELOW GRADE fl JOINTS: ❑ WELDED El-THREADED O OTHER DIAMETER in. SEAL: ELCE-MENT GROUT ❑ BENTONITE ❑ OTHER WEIGHT PER FOOT Ib. /ft DRIVE SHOE ❑ YES - LINER. OYES lam! SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (It) DEPTH TO SCREEN (ft) DEVELOPED? FIRST OYES ONO HOURS- GRAVEL PACK O YES ❑ NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST If detailed pumping t METH O PUMPED tests were done is in- OMPRESSED AIR , formation attached? O BAILED ❑ OTHER i ❑ YES O NO 'WELL LOG if more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFACE Water Bear- In9 Well Oia- Deter FORMATION DESCRIPTION CODE, tt. ft. WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gFm. Surface (� WATEI O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ❑ NO ANALYSIS ATTACHED? .O YES O NO _ STORAGE TANK: TYPE CAPACITY GAL. WELL diri d DRILLERNAME Aq/e-'F"'rfvAGf'1=RE A444' WA M P.0 j57 �` S—Cr (4), (/a �% PUMP INFORMATION TYPE CAJ W ICE CAPACITY MAKER � a "C DEPTH MODEL VOLTAGE: HP PUTNAM COMFY DEPARTMENT OF HEALTH a - _._....._. _.... , -.D _S1 i O,. FNVIRO� 'I�TrAL:HEALTH..SERVLCFS. - .. - .v....v _. _�. ...— ,....i. .. �s —�_ 4t Pine. -....n Ha.M ._.. ^ry rs`;.. ..• Owner or Purchaser of Building iJ Building Constructed by Building Type Section Block Lot Subdivision Name � =1 - Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, worlananship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to ., operate: for.a.period of two years immediately following the date of approval of the erificte -o� Cons: trutaiiCompllance "_ f= ©r:_th .sue -e-dispG�:. 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 the building utilizing the system. Dated this day of v 19'7- � Signature Title General Con actor (Owner) - Signature CJ i� '�d� zfeai� Corporation Name (if Corp.) Corporation Name (if Corp.) Address Address rev. 9/85 mk TT. Putnam County Department Of Health jjDivision of Environmental Health Servioea 1. Approved as noted for aonfor'anoe with appl Rules and Regulations of the Co -$ealth Departure %zlr� h S gnature & Title at lr.• .. f.,, 7r. 1 /' r� �• .� -'•c y ro i' a }r"0.' � l x � } ., g t y N!' 5�:.L'o�f✓ apt ,✓dC�C,.%�erJa # ^� "This. is to dertifg that. tlne sewage di€ M, ar donetructed &e indicated -on, his plan `. was inspected b�_ me be�o�e it.. c system "was_conetruoted in accordance! rules and regurations of: the Putnam CQu ,..._., YorlDe Health and the Jew artmR e:b9• M1 S- an u. '-^Y. �<. ,[ } v'z'.e• 74 3.Y t' $f} .A��'i�.X - :f:..'i A,' I L ��^_ — - r. j/