HomeMy WebLinkAbout4286DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.83 -1 -23
BOX 32
'
r-
�I r
�� =
,
ARIV7. /R6
•I ER C
.
Located
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Mast Provide
P.C.H.D. Permit N —�
E FOR SEWAGE DISPOSAL
Owner /applicant NameP, Dee a n � . 4 i= Forme
/ rly
Mailing Address R 0 2is y Z JCffyi"O" 4/1*Z1p
„ !41 11 f Hn 14 /A? y- _
"•-Town or Vifte
Tax Map l D // Block�
�� lo
Subdivision Names I�0L�S�;
Date Permit Issued
Separate Sewerage System built by 1911 Aoeir✓ Address i` e'Gd v �i a- /&I . `G Al 6 : i
Consisting of Gallon Septic Tank and s�5 L d ill. >`YGX c:
Water Supply: Public Supply From Address
or: — Private Supply Drilled by41a A l d tai n Address PCd hG1h l< //P:z
Building Type Lon L%) __Has Erosion Control Been Completed? ALP
Number of Bedrooms _,� Has Garbage Grinder Been Installed? /J0-
Other Requirements
i aaaaiEY Ohaa Yi�e- eyre:.u.Fli -- - - -- -- y- e ebeve ( copies
bosls' wales and r he
/i �N X e L AJo es a 4? O J14 d e Cd
01
Date C En d Arat6 i Certified by r ,'
n P .Ef . __,t�_ s � �R.A�i.
IF
Address �PJ1 44-106 V -7 6,6 �rec�e l/
�JJ
License NO.
Any person occupying premises served by the above system($) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a pub(': sanitary sawer becomes
available and the approval of the private water supply shalt become null and void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the Judgment of theeCCo�mm�lsstiioner of Health, such revocation, modification or change Is necessary.
Date % K �y TItdF
_CtyiJhTY -or, WESTOIESTER _
AMMU WATER FILTRATION PLANT
Results of Examination of Water
Laboratory No.. Collected by Set b
/ Y
Date Collected Set Reported
DISTRICT: T - in ow SAMPLING POINT: SINK
U E1;
Owner �_�•� -�� Address - -, �.��r ��.r� _.'o:%
Chlorins: Free PPM or Total 1- �PPt4 -`'
Color_ Units Turbidity •p Units Fluoride MG/1
BACTERIAL EXAMINATION: Membrane per 100 ml < P H Yolue
wa s ) .
These results indicate the source of the sample of a satisfactory bacterial quality for the indicated use
was not
the sample was collected.
i
J 1
01-X4+ T.TV T T nAMDT V rTnNT DVDnVrr
vypj�j�
DEPARTMENT OF HEALTHY Qty
Dh -at
v! .a H
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
SIR ADORES S. CIIY TAX GRID NUMBER:—
WELL OWNER
DRESS: 44 - -&PBIVATE
❑ PUBLIC
USE OF WELL
I - primary
2 - secondary
9CRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/ HAT PUMP ❑ eBAND-ONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./ NO. PEOPLE SERVED EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
WNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH —13 0 0 f
TtS STATIC WATER LEVEL -j1:EftTDATE
MEASURED
DRILLING
EQUIPMENT
ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. )Z/OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH ft-
MATERIALS: XSTEEL ❑ PLASTIC 0 OTHER
LENGTH.BELOW GRADE ft.
JOINTS: ❑ WELDED JkNBEADED ❑ OTHER
—'DIAMETER in.
SEAL: O CEMENT GROUT 0 BENTONITE MOTHER
WEIGHT
PER FOOT /T lb./ft-
I DRIVE SHOE.AYES-0 NO
LINEFLOYESXMO
SCREEN
I DIAMETER (in)
SL07 SIZE
LENGTH (ft)
DEPTH TO SCREEN (IQ
DEVELOPED?
-S.
ETAI-L
FIRS T--
0—YES , Ne
_ff
SECOiTD*-'---
HOURS
GRAVEL PACK
❑ YES
0 NO
GRAVEL
SIZE:
DIAMETER
OF PACK. in. I
TOP
DEPTH —ft..
BOTTOM
OEM — it.
WELL YIELD TEST If detailed pumping
�I§IHOD: 0 PUMPED tests were done is in-
COMPRESSED AIR formation attached?
0 BAILED ❑ OTHER '0 YES ❑ NO
WELL LOG
-It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
W"e'
81,
hg
Well
Oia -
Meter
FORMATION DESCRIPTION
COOS.
ft .
WELL DEPTH
it.
DURATION
hr, min.
DRAWOOWN
it.
YIELD
1.2nd
surlace
Ar
WATE9 CLEAR TEMP.
QUAO CLOUDY HARDNESS
LI �
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
STORAGE TANK: TYPE
CAPACITY GAL. 10-
WELL ORIL NAME
ADORES
>
-77. ►
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MO-DEL'-'§ VOLTAGE�1— HP
P,UTNAM.COUNTY DEPARTMENT OF HEALTH
- a; VI5MR— OF-EZ�'J�1Fcl�VMMM `HEALTH TMVrc�TS
Owner or Purchaser of Building
o�.tiz.P
Building Constructed by
Location - treet
Municipality
Building Type
Section Block Lot
Subdivision Name
Subdivision Lot #
'GUARANTM OF SUBSURFACE SEWAGE.DISPOSAL SYSTIM
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
t,e for a icd- •of - two eam, mmediate1 fo -11aw� the .date of . a royal -of the. :..
- 9a�_..�.... Per. Y . ,._ . _....._.,_. ?'. .:. ..q. PP -r
"Certificate of Construction Compliance" for the` sewage- disposal'systee, "-bt ariy
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 _2&�— 19-Zn;
iq./ ✓W S
General Con actor (Owner) - Signature
-Az- W^ �"-f f CAZJ 0'->
Corporation Name (if Corp.)
C? ell
Address
rev. 9/85
mk
Signature
Title i
)MOT
1 IE-L 'fib J�'"?tad'U/0oi��'dc
Corporation Name (if Corp.)
SL5epo? 0 /�I9W6000c
Address
ii.
4�
• `1
1f
1:1iE EAST
30'
30
JBS
i
35'
183
35, 18 Z
TS
gor..
f
r�r L = 9.o4 ,
•�t
:W `di
bM4
s
N �y
ai•
R
i
6
P
30'
30
JBS
i
35'
183
35, 18 Z
TS
gor..
Io-
I
!i
/ 37, ?6'
i
Ak -4 +: �
i 1
30'
4-O
35' /k- loo' K T4 ;
/ We L.Lw
l0004��,
PRE - CA5-r cowic, PLAW 16Y
545M 4c- TAW K OT1�Z5 ;
,i
ro Dis Ns�A• �
3 F� /ice
PA
PROM r�s R9cn ve
PA I 5V-,D f3Ll��� • cowl ElZS
Putnam Co ty Depaxtmert o-t Hea.l. I
J.ivision of. E ironmontal Health Servi'll.
!.pprovod�as+n' a,ed` for Conformance with.)
-. ..:.,,..,.).3'3;iOn8 of the
',.,team C01;;rty Hoalth
�5c e 2 0,
AS BUILT MEASUREMENTS:
LOCATION A B
Septic Tank @ 3112" 1410"
JB 1 37111" 2414"
JB 2 4119" 2864"
JB 3 4519" 3414"
JB 4 49'9" 4010"
JB 5 53'9" 4516"
JB 6 5719" 5114"
NOTES:
I. House location and boundary survey
obtained from foundation plan and survey
prepared by Badey and Watson dated Sept.
14, 1976; premises designated as Lots
15 thru 22, Block 8 on "Map of Lake
Peekskill - Section B ".
2. Sewage disposal system shown is based
upon measurements supplied by owner
which were spot checked by engineer
during field inspection of approximate
exposed ends of trenches on Feb. 14,
1987.
0� 3. Engineer did not supervise construction
ryj of this sewage disposal system and has
b prepared this plan to show the as built
well location, septic tank location
and approximate sewage absorption trench
configuration and location.
Q
1
— A's - F3 u I
J)AVIV VCi�.1N f�DT
:W `di
ai•
R
a
1�i
,i-
DeILI�
;
WELL-
r.
�f
ay
:1
Io-
I
!i
/ 37, ?6'
i
Ak -4 +: �
i 1
30'
4-O
35' /k- loo' K T4 ;
/ We L.Lw
l0004��,
PRE - CA5-r cowic, PLAW 16Y
545M 4c- TAW K OT1�Z5 ;
,i
ro Dis Ns�A• �
3 F� /ice
PA
PROM r�s R9cn ve
PA I 5V-,D f3Ll��� • cowl ElZS
Putnam Co ty Depaxtmert o-t Hea.l. I
J.ivision of. E ironmontal Health Servi'll.
!.pprovod�as+n' a,ed` for Conformance with.)
-. ..:.,,..,.).3'3;iOn8 of the
',.,team C01;;rty Hoalth
�5c e 2 0,
AS BUILT MEASUREMENTS:
LOCATION A B
Septic Tank @ 3112" 1410"
JB 1 37111" 2414"
JB 2 4119" 2864"
JB 3 4519" 3414"
JB 4 49'9" 4010"
JB 5 53'9" 4516"
JB 6 5719" 5114"
NOTES:
I. House location and boundary survey
obtained from foundation plan and survey
prepared by Badey and Watson dated Sept.
14, 1976; premises designated as Lots
15 thru 22, Block 8 on "Map of Lake
Peekskill - Section B ".
2. Sewage disposal system shown is based
upon measurements supplied by owner
which were spot checked by engineer
during field inspection of approximate
exposed ends of trenches on Feb. 14,
1987.
0� 3. Engineer did not supervise construction
ryj of this sewage disposal system and has
b prepared this plan to show the as built
well location, septic tank location
and approximate sewage absorption trench
configuration and location.
Q
1
— A's - F3 u I
J)AVIV VCi�.1N f�DT