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Home My WebLink About4027DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.65 -2 -25 BOX 31 04027 LK U PUTNAM COUNTY DEPARTMENT OF HEALTH ® ® DIVISION OF ENVIRONMENTAL HEALTH SERVICES ... .. _. ....... gab•. ..a. "e• a.. .... :•-C ':' .:� _ "c•• • _ :m s:� +..... ,y.� ^' .. .. s .. _ ... APPLICATION TO CONSTRUCT A WATER WELL T please print or type Well Location Street Address: Town/Village: Tax Map # 1p Block Lot(s) Well Owner: Name: Address: Ppoq? #: W1/r't-V [ e4 At J'L+f. 1017,/ 1��f�rca 40 � %Ares3; e4 -cep % Use of Well: Residential _Public Supply Air /cond /heat pump _Irrigation rimary Business Farm Test/monitoring _Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought b� gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason ,, a ii a v for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes _ No t;>' Is well located in 'a realty subdivision? ........................................... ............................... Yes _ No �✓ Name of subdivision Lot No. Water Well Contractor: /✓mvw,, ,, 44 "C- -eV dgy, Address: Js a gqG rip e.,. S4-. ,�ii,u,�. I� IfP Is Public Water Supply available on site? ..................... ............................... ".............' Yes Nol� Name of Public Water Supply: TownNillage Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: ,� Applicant Signatpr�e: r<; U'1- 1�c�R6(�u►1 _ _ ,I � .�.. _ .,_ _ .._ _.. PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Departmei take appropriate action to assure that any and all water and 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. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue 8/I �� Permit Issuing Official: Date -of ExpirationR /, /14,4 Title: A44c hee;, `6 Te Permit is Non - Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 st f 'j AS DUIL'T DRAWING .s 'b +J� ( h LA' r JEU Ll h T f tf G i • Z; zo -o •`. �.. � �� • ° _ �- Z�� -ter �f Z. LEONARDI AND SON CONSTRUCION INC. 6 CAROLYN DIL CORTLANDT MANOR, NY 10567 j 1 (914) 980 -3554 V t:l DATE: In —2 f Putnam lic.# PC -S60 West. Llc.# 061 .f � PUTNAM COUNTY HEALTH DEPARTMW DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL EM SBaGE DISPOSAL SYSTEM REPAIR OWNER'S, NAME K�,,r,7�\ 6A v 4- py-c, Pa2ZJQRHCNE 0 SITE LocATION cz Z.5 MAILIM ADWMS—B r) x. Lcx L' e— Pe � 1 7 /)-SL::1 ' r— — V-1 - - P&rDCN INTERVIEWED 7T77r7r-�V-% f nq- );�,,-Y-%na 0Lk-,rLe.r� PCHD Caq3laint # Nam & Relationship (i.e, owner,,tenant, etc.) DATE --/0- qY TYPE FACILITY PROPOSED INSTALLER PHONE 0 Q REGISTRATION # ft4l Proposal (include sketch locating all adjacent wells): NOM: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. L') -r- Proposal approved Proposal Disapproved Inspector's Signature & Title Proposal amroved with the following conditions: 1. Procurement of any Town permit, it applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Nam, Town and Tax Map number. c. Location of installed caqments tied to two fixed points (e.g.,house corners). d. System description (e.g.,, 1250 gal. concrete septic tank,, three precast 61 diem. x 61 deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE OMM: hbite (PCHD); YeUcw ('fin ECD; Pink (PVpliaint) TITLE Ci /PUTNAM COUNTY HEALTH DEPARTMENT ✓ J DIVISION OF ENVIRONMENTAL HEALTH SERVICES ® ® I Q __.. � _ _ • ��:_I?S rrS��. F;%!R ;SE1°+♦ierzF .'!<'RlE:�T�4E;�9?� yS � F$F�AI! YES NO Internal Use Only PERMIT #, R, o:S l -t Y El ❑ � Repair Permit issued in last 5 years Not in Watershed ,_ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated 11 LV ,/ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION 'U6 L&Iza- Dr TOWN Pu y V6e'lIel TM # $1j, GS OWNER'S NAME Ject-y., 1= V i . PHONE # 517 796 60q-(o MAILING ADDRESS (17 7 - i 1� r✓p �t^ �,r p � 5Q 6 3 D APPLICANT Zvuis L100Ad Name & Relationship (i.e., owner, DATE FACILITY TYPE 2, F& Re_.� PCHD COMPLAINT # PROPOSED INSTALLER /cc.Aj PHONE # ADDRESS ;9r- REGISTRATION /LICENSE # DG (o0 Proposal (Include a separate sketch locating the house, property lines, all adjacent wells with n 200 1 I feet of repair and the location of existing and proposed system) (� ( t 7 ) 6 — q 3 1 1 NOTE: The Department may require submittal of proposal from licensed professional dependiri�g-on the nature and extent of the repair. I, as owner,agree to the conditions stated on this form SIGNATURE .(owner)-.. _.-. -7 inha-selflic-if TITLE bNVfL a P— DATE .._. , iiei, ag ill _fiiply with a E-c�:nvitiu�-�S u` +'i� �� pGr� ifar't�ie SIGNATURE �-'� �,e T r DATE — =f (installer) Proposal aparoved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2: Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. IWYCOWAI IICC AWI V .� V1._ _J V _ I Proposal Approved Proposal Denied ❑ 02, Eh-VI, InspMoes Signafure & Title Dale Ex ration Date .Repair proposal is in compliance with applicable codes Yes 0 No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 6 Putnam County Department of Health Division of Environmental Health Services Date: 616-Ml SSTS Repair — Final Sit bspection Da Inspected by: Wer Installer: Street Lo Vc, I 1e Y Owner: Town: cAl4ridl Rep*.PerMft#: # 'k W.: 1. Type of System: Conventional Alternate Comments: 2. Sep tic Tank Yes- No -N/A I Cnvnrn.+. a. Septic tank size — 1,000... 1,250 other . b. Septic tank installed level ................ ...... P. 101 minimum from foundation .................. d. Distribution Box � 4-A) I '? i. . All outlets at same elevation (water tested) ii. Protected below frost ............................. ------------ iii. Minimum 2 & Original soil between box & trenches L/ e. Junction Box — properly set ............................ • f Trenches i. System completely opened for inspection ii. Lm* required _ Length installed W iii. Pipe slope checked ........... iv. Installed according to plan ..................... v. 10 ft from property line — 20 ft — foundations ... vi. Size of gravel % -1 diameter clean ......... vii. Depth of gravel in trench 12" miniminn ......... 3. * SewaEe System Area a. SSTS Area located as per approved plans b. Fill section — - c. Distance from water course/wetlands 4. Overall Workmanship a. * Boxes properly grouted and installed correctly ........... b.. All pipes flush with inside of box ......................... c. Backfill material contains stones <4" diameter ......... d. Curtain drain & standpipes installed according to plan e.. Curtain drain outfall protected & dir to exist watercourse f, Footing drains discharge away from SSTS area ......... g. Erosion control provided ............................ Additional Comments: Vi'. 50y'.i Q.no", C.- 12FS1 Rev - 011312 A ll� 0 L04 -30 vJ � 0 � 4Do5 &--- m �JAOIV ALLEN BEALS, M.D., J.D. CQmmWOW ofHed& DkVdor ofAwftnmeNdHeafth Ms. Jean.Lui Nk. William Lui 10231 Pimlico Drive Cypress, CA 90630 MARYELLEIV .ODE.LL DEPARTMENT OF REALT11P 1 Geneva Road, Bwwster, New York 10509 Phone # (845) 800 -1390 Pau # (&45) 278 7921 Certified Return Receint Requested Please Refer Correspondence t .Name: Lisa Seymour Title: Public Health Sanitarian Phone: (845) 808 -1390 Ek 43 Date: April 27, 2014 Official Notice of Non- CoinDliance YOU ARE HEREBY NOTIFIED that non - compliance with Article III Section 3.4 of the Sanitary Code consisting of a discharge of sewage on the surface of the ground was foun Lake Peekskill, NY, 10537, TM# 83.65 -2 -25, by a representative of this Department on) C' - Lake Drive, . -2014 It is .believed that you are responsible for correction of this condition. If you are not responsible, you are requested to notify immediately the inspector'above indicated Please be advised that appropriate steps must be. taken immediately in order that the sewage overflow cease by arranging for the septic tank to be pumped out and maintained pumped _until the mmm-r. -►- - •'tai tF.e�s3}s`eeem._� ,y -ie+.. � Approval of proposed. repairs must be obtained from this Department prior to any alteration or rebuilding of existing disposal systems. Enclosed is an application and a fist of licensed contractors. Failure to pump the septic tank immediately and further, to correct this condition by Junie.6,2014 will make you liable for additional penalties provided by law, including prosecution on a charge of committing a violation punishable by a fine or imprisonment, or both such fine and imprisonment, as prescribed by law; in addition to such other action as may be prescribed. The septic system is required to be maintained / pumped until repairs are. A re- inspection will be made. It is sincerely hoped that the above mentioned further action will not be necessary and that you will cooperate by securing the correction of this condition. LS /jmg Comp. # 105- 14 -19OW cc: BI (T) PV M. Burdick G. Reed For the Commissioner of Health All Beals M.D., J.D 7, By: LisaZeymour Public Health Sanitarian II ITE -,I-. I- -, R 011D OF TEL PH-l"' COI -ITIRESSATION PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmenal Health Services Facility: Town: Time: /A." ss-01m Date: Telephone# Caller's Name: ZC/ 36 /0 D. DISCUSSION: r-orlev, Signed: Date: Rev. 6/97 lei I 2-So tccxt-l— �-�- � C sb r / v `' FEE S ..4 .p e E P PD4411 01- V Vi�Lk v'a- K PUTNAM COUNTY HEALTH DEPARTMENT 1 t� DIVISION OF ENVIRONMENEAL HEALTH SERVICES PROPOSAL FOR SERM DISPOSAL SYSTEM REPAIR OWNER'S NAME L - P A'- i�jllv�- PC SITE IQCATION MAILING ADDRESS PERSON INTERVIEWED AV7-1- -p.i -- t�rt— �..��c.:."ir C' =�4•, i PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE - ' % �� -' -- - -- -- - _ TYPE FACILITY %J PROPOSED noTALLIIt Y 1i::. •, k_ b\ t i. REGISTRATION # t4 J Proposal (include sketch locating all adjacent wells): Non: Repair must be in same location and of same type as original Different location may require submittal of proposal from licensed registered architect. PHONE sewage disposal system. professional engineer or i" rviL Proposal approved Proposal Disapproved s Signature & Proposal awroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. .b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGM(ktE Q3�'gS: *Ate MD); %lkw (fin ffi); Pink (AF Ummt) PC -RP 97 TITLE t DATE L.l .•� TM a'e%.,GP:..pv P ^ .T..�.s .. n: V.VI'aIC"- f..++.J�w -- Y . r..1. -.r _: ♦ � r'.t' .wJ .4Re.'iar � r'.f r-.a ... •. .;.Y e'='7 i:MA •'� � .Y . n.ti..: . Y .:. ♦ .. V . Jam. '1/.: ' �I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner. L y l Addreas: Located at (street): 30C Ga /�c TM # Municipauty: If V Watershed: SOIL PERCOLATION TEST DATA Witneaud by: Date of Pro-soaking: Date of Percolation Test: i Hole No Hole depth (Inches) Ran No. Time Start — Stop Elapse Time (min.) Depth to wetter from ground surface (ink) Start- stop Water level drop. in inches Percolation Rate main/inch 4 1 2 3 4 5 1' 2 3 4 5 1 2 3 4 5 motes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., :5 1 min for 1 -30 min/inch, < 2 min for 31 -60 min/inch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Fong DD-97, pg I of 2 TEST Pff DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES G.L. 0.5' r 9.0' r " 2.0' 2.6' It C ;)i� 3.0' 3.5' xr P 12 .11 4.0' 4.5'x 5.0' 5.5' (5- 6.0' 6.5' 70' 7.5' 6.0' 6.5' 9.0' Indicate level at which groundwater is encountered `t Indicate level at which mottling is observed' Indicate level to which water level rises after being encountered d Deep hole observations made by: .i` fa Date Design Professional Name: Address: Signature: Design Professional's Seal � I Revised July 2013